Introduction
Infertility is when a couple fails to conceive (get pregnant) despite having regular unprotected sex. Although one in seven couples has difficulty conceiving, the number of couples who are actually infertile is relatively low.
About 85% of couples will conceive naturally within one year if they have regular unprotected sex. Of 100 couples trying to conceive naturally:
- 20 will conceive within one month,
- 70 will conceive within six months,
- 85 will conceive within one year,
- 90 will conceive within 18 months, and
- 95 will conceive within two years.
Therefore, you will only be diagnosed as infertile if you have not managed to have a baby after two years of trying. If you have never conceived a child, it is known as primary infertility. Secondary infertility is when you have had one or more babies in the past, but you are having difficulty conceiving again.
Some women get pregnant very quickly but, for others, it can take longer. Although there is not a cut off point to say when a couple is infertile, it is best to see your GP if you have not conceived after one year of trying.
If you are a woman over the age of 35, or you are already aware that you may have fertility problems, then you should see your GP sooner. They may be able to check for common causes and suggest treatments that could help. If fertility problems are diagnosed, there are many different treatments and procedures that may be available to you.
For couples who have been trying to conceive for more than three years, the chance of a pregnancy occurring within the next year is 25% or less.
Causes of infertility
Infertility can be caused by many different factors and, in 30% of couples, a cause cannot be identified.
Infertility in women
Ovulation disorders
Infertility is most commonly caused by problems with ovulation (the monthly release of an egg). Some of these problems stop women releasing eggs at all, and some cause an egg to be released during some cycles, but not others. Ovulation problems can occur as a result of a number of conditions that are outlined below.
- Premature ovarian failure - when your ovaries stop working before the age of 40.
- Polycystic ovary syndrome (PCOS) - a condition which makes it more difficult for the ovaries to produce an egg.
- Thyroid problems - both an overactive and an underactive thyroid can prevent ovulation.
- Chronic conditions - if you have a debilitating condition, such as cancer or AIDS, it can prevent your ovaries from releasing eggs.
Womb and fallopian tubes
The fallopian tubes transport an egg from the ovary to the womb, where the fertilised egg will grow. If the womb or fallopian tubes become damaged or stop working, then it may be very difficult to conceive naturally. This can occur following a number of procedures or conditions, as outlined below:
- Pelvic surgery - this can sometimes cause damage and scarring to the fallopian tubes.
- Cervical surgery - this can sometimes cause scarring, or shorten the cervix (neck of the womb).
- Submucosal fibroids - are benign (non cancerous) tumours that develop in the muscle underneath the inner lining of the womb, and may prevent implantation.
- Endometriosis - this is a condition where cells, normally found in the womb lining, start growing on other organs. This can cause adhesions in the pelvis and limit the movement of the fimbria (tiny fronds at the end of the fallopian tubes) which direct the egg into the tube.
- Previous sterilisation - some women choose to be sterilised if they do not wish to have any more children. Sterilisation involves blocking the fallopian tubes to make it impossible for an egg to travel to the womb. This process is rarely reversible. If you do have a sterilisation reversed, it will not necessarily mean that you will become fertile again.
Medicines and drugs
The side effects of some types of medication and drugs can affect your fertility. These medicines are outlined below.
- Non-steroidal anti-inflammatory drugs (NSAIDs) - long-term use or a high dosage of NSAIDs like ibuprofen or aspirin can make it more difficult to conceive.
- Chemotherapy - the medicines used with chemotherapy can sometimes cause ovarian failure, which means your ovaries will no longer be able to function properly. Ovarian failure can be permanent.
- Illegal drugs - drugs such as marijuana and cocaine can seriously affect your fertility, making it more difficult to ovulate. They may also adversely affect the functioning of your fallopian tubes.
Age
Infertility in women is also linked to age. Women in their early twenties are about twice as fertile as women in their late thirties. The biggest decrease in fertility begins during the mid thirties.
Infertility in men
Semen
The most common cause of male infertility is abnormal semen (the fluid ejaculated during sex that contains sperm). Abnormal semen accounts for 75% of male infertility cases, and the cause of abnormal semen is often unknown. Semen can be abnormal for a number of reasons which are outlined below:
- Decreased number of sperm - you may have a very low sperm count, or have no sperm at all.
- Decreased sperm mobility - if you have decreased sperm mobility, it will be harder for your sperm to swim to the egg.
- Abnormal sperm - sometimes sperm can be an abnormal shape, making it harder for them to move and fertilise an egg.
Many cases of abnormal semen are unexplained, but there are several factors which can affect semen and sperm.
Testicles
The testicles are responsible for producing and storing sperm. If they are damaged, it can seriously affect the quality of your semen. This may occur if you have:
- an infection of your testicles,
- testicular cancer, or
- testicular surgery.
Ejaculation disorders
Some men have a condition which makes it difficult for them to ejaculate. For example, retrograde ejaculation, causes you to ejaculate semen into your bladder. The ejaculatory ducts can also sometimes become blocked, or obstructed, and this too can make it difficult to ejaculate normally.
Medicines and drugs
- Sulfasalazine - this is an anti-inflammatory medicine used to treat conditions such as Crohn's disease (inflammation of the intestine) and rheumatoid arthritis (painful swelling of the joints). This medicine can decrease your number of sperm. However, its effects are only temporary, and your sperm count should return to normal when you stop taking it.
- Anabolic steroids - these steroids are often used illegally to build muscles and improve athletic performance. Long-term use, or abuse, of anabolic steroids can reduce your sperm count and sperm mobility.
- Chemotherapy - the medicines used with chemotherapy can sometimes severely reduce the production of sperm.
Factors that affect both men and women
There are a number of factors that can affect fertility in both men and women. These include:
- Weight - being overweight, or obese, reduces both male and female fertility. In women, it can affect ovulation. Being underweight can also impact on fertility, particularly for women, who will not ovulate if they are severely underweight.
- Sexually transmitted infections (STIs) - there are several STIs which can cause infertility. The most common is chlamydia, which can damage the fallopian tubes in women and cause swelling and tenderness of the scrotum (pouch of skin containing the testes) in men.
- Smoking - not only does smoking affect your general and long-term health, it can also affect fertility.
- Occupational and environmental factors - exposure to certain pesticides, metals and solvents can affect fertility in both men and women.
- Stress - if either you or your partner are stressed, it may affect your relationship. Stress can reduce libido (sexual desire), therefore reducing the frequency of sexual intercourse. Severe stress may also affect female ovulation and can limit sperm production
Diagnosing infertility
When to see your GP
About 85% of couples conceive naturally after one year of unprotected sexual intercourse, so if you have not conceived after one year, you should visit your GP.
If you are worried about your fertility, or you are a woman over the age of 35, then you should visit your GP sooner. Fertility testing and investigation can be a lengthy process, and female fertility decreases with age, so it is best to make an appointment early on.
Your GP will be able to give you advice about what to do next and will also carry out an initial assessment to look for factors that may be causing your fertility problems.
It is always best for both partners to visit their GP because fertility problems can be caused by a male or female or, in some cases, both.
The process of trying to conceive can be a very emotional one, and it is important that you try and support one another, as stress is just one of the many factors that can affect fertility.
Medical, sexual and social history
When you visit your GP, they will carry out a full medical, sexual and social history in order to identify any possible factors which may be causing fertility problems. Your GP may discuss the following with you:
Children - your GP will ask a woman if she has given birth previously and will enquire as to whether there were any complications with the pregnancy. They will also ask about any miscarriages. The man will also be asked about whether or not he has had any children from previous relationships.
Length of time trying to conceive - if you are young, and in good general health, it is likely that you will be able to conceive naturally. 95% of couples are able to conceive naturally after two years of having unprotected sex. If you have not been trying for a baby for very long, you may be advised to keep trying for a little longer.
Sex - you may feel uncomfortable, or embarrassed, about discussing your sex life with your GP. However, it is very important to be honest and open about this because the problem can sometimes be difficulty with sex which can be easily overcome.
Length of time since stopping contraception - your GP will consider the type of contraception you were previously using to see whether it may be affecting your ability to conceive. Sometimes, it can take a while for certain types of contraception to stop working.
Medication - the side effects of some medication can affect fertility. Your GP will therefore look at any medication you are taking and might discuss alternative treatments with you. You should inform your GP about any non-prescription medication that you are taking, including any herbal medicines.
Lifestyle - smoking, weight, alcohol consumption and stress can all affect fertility, so your GP may discuss ways that you could improve your lifestyle, and therefore increase your chance of conceiving. After taking a medical, sexual and social history, your GP may conduct a physical examination, or refer you for further tests.
Physical examination for women
When carrying out a physical examination, your GP may:
- weigh you to see you if you have a healthy body mass index (BMI) for your height and build,
- examine your pelvic area to check for vaginal infection, or tenderness, which could be an indication of endometriosis, or pelvic inflammatory disease (PID) - see Causes, above.
After your GP has considered your medical history, and carried out a physical examination, they may refer you for further tests and procedures, as outlined below.
Tests for women
Pelvic ultrasound - uses high frequency sound waves to create an image of an organ in your body, in this case an image of your womb and ovaries.
Progesterone test - this blood test checks to see if you are ovulating. The test should be taken seven days before you expect a period.
Chlamydia test - chlamydia can affect fertility. If you have chlamydia, your GP will be able to prescribe antibiotics to treat it.
Thyroid function test - it is estimated that between 1.3% and 5.1% of infertile women have an abnormal thyroid.
Hysterosalpingogram - this is a type of X-ray that checks your fallopian tubes.
Laparoscopy - a small cut is made in your lower abdomen and a thin, tubular microscope, called a laparoscope, is used to look more closely at your womb, fallopian tubes and ovaries. Sometimes, dye is injected into the fallopian tubes through the cervix (entrance to the womb) to highlight any blockages.
Examination and tests for men
During a physical examination your GP may:
- check your testicles for any lumps or deformities, and
- check your penis to look at its shape and structure and to look for any abnormalities.
Further testing can include:
- Semen analysis - your semen will be tested to see if you have a low sperm count, low sperm mobility, or abnormal sperm.
- Chlamydia test - chlamydia can affect fertility. If you have chlamydia then your GP will prescribe antibiotics to treat it.
Treating infertility
Eligibility for treatment
Fertility treatment, funded by the NHS, currently varies across the UK. In some areas, waiting lists for treatment can be long. The criteria you must meet in order to receive treatment can also vary.
Your GP will be able to advise you about your eligibility for treatment. If your GP refers you to a specialist for further tests, the NHS will pay for this. All patients have the right to be referred to an NHS clinic for the first investigation.
Going private
You may wish to consider private treatment. Private treatment for infertility can be very expensive, and there is no guarantee that it will be successful. For example, a cycle of in vitro fertilisation (IVF) at a private clinic typically costs between £4000 and £8000, depending on the clinic and treatment selected.
It is important to choose a private clinic carefully. Find out what clinics are available, the treatments they offer, their treatment success rates, the length of the waiting list, and the costs.
You can ask your GP for advice, and should make sure that you choose a clinic that is licensed by the Human Fertilisation and Embryology Authority (HFEA).
The HFEA is a government organisation that regulates and inspects all UK clinics providing infertility treatment, including the storage of eggs, sperm or embryos.
Treatment options
There are three main types of fertility treatment:
- medicines to assist fertility,
- surgical procedures, and
- assisted conception.
Medicines to assist fertility
- Clomifene - this medicine helps to encourage ovulation (the monthly release of an egg) in women who do not ovulate regularly, or who cannot ovulate at all.
- Metformin - you may have to take this medicine if you have not responded to clomifene. It is particularly beneficial to women with polycystic ovary syndrome (PCOS) - see causes section.
- Gonadotrophins - medicines containing gonadotrophins can help to stimulate ovulation.
Surgical procedures
- Fallopian tube surgery - if your fallopian tubes have become blocked, or scarred, you may require surgery to help repair the tubes and make it easier for eggs to pass along them.
- Laparoscopic surgery - a laparoscopy involves having a small cut (incision) made in your abdomen. A thin, flexible microscope with a light on the end, called a laparoscope, is then passed through the incision. This type of procedure can be used to look at internal organs, take samples and perform small operations. It is often used for women who have endometriosis - see 'causes' section.
- Epididymal blockage - this type of surgery is used to repair the epididymis (a coil like structure in the testicles which helps to store and transport sperm). Sometimes, the epididymis becomes blocked which can stop sperm from being ejaculated normally.
Assisted conception
Intrauterine insemination (IUI): This procedure involves sperm being placed into the womb through a fine plastic tube. The tube is passed through the cervix and into the womb. Sperm is collected from the man and then washed in a fluid, after which the best quality specimens are selected. The sperm are then passed through the tube. This procedure is performed to coincide with ovulation and increase the chance of conception. You may also be given a low dose of ovary stimulating hormones to increase to chance of conception.
IUI tends to be used when infertility cannot be explained, or when a man has a low sperm count, or decreased sperm mobility. It is also helpful for men who experience severe impotence. Provided that the man's sperm and the woman's tubes are healthy, the success rate for IUI is around 15% per cycle of treatment.
In vitro fertilisation (IVF): In IVF, fertilisation happens outside the body. The female partner takes fertility medication to encourage the ovaries to produce more eggs than normal. Eggs are then removed from her ovaries and fertilised with sperm in a laboratory dish. The fertilised embryos are then put back inside the woman's body. The NHS aims to provide at least one funded cycle of IVF treatment for couples who meet certain criteria. For more information, go to Health A-Z: IVF
Egg and sperm donation: If a couple have an infertility problem, they may be able to receive eggs or sperm from a donor to help them get pregnant. Fertility treatment with donor eggs is normally carried out using IVF. Anyone who registered to donate either eggs or sperm after 1st April 2005, can no longer remain anonymous and has to provide information about their identity. This is because a child who is born as a result of eggs or sperm being donated is legally entitled to find out the identity of the donor, upon reaching the age of 18.
Blastocyst transfer: Blastocyst transfer treatment is sometimes used for women who are able to make good quality embryos that fail to implant in the womb. In this procedure, embryos are allowed to develop for five to six days after fertilisation before they are put back in the womb.
Assisted hatching: In order to attach to the wall of the womb, an embryo first has to break out ('hatch') from the gel-like shell that it is contained in. This shell is called the zona pellucida and is harder in some embryos than others. Assisted hatching is when the doctor helps the embryo to hatch by making the shell of the embryo thinner, or by making a small hole in its shell.
Complications of infertility
Some of the treatments for infertility can cause complications. These are outlined below.
Ovarian hyperstimulation syndrome (OHSS)
OHSS causes your ovaries to swell, and to produce too many follicles (small fluid-filled sacs in which an egg develops). It most commonly occurs after the use of medicines that stimulate your ovaries, such as clomifene and gonadtrophins. It can also develop after IVF. Symptoms may include:
- nausea,
- vomiting,
- abdominal pain,
- bloating,
- constipation,
- diarrhoea, and
- dark, concentrated urine.
The symptoms are often mild and can be easily treated. However, severe cases of OHSS can lead to thrombosis (a blood clot in the artery or vein), liver and kidney dysfunction, and respiratory distress. Severe OHSS is a potentially life-threatening condition.
Ectopic pregnancy
The word 'ectopic' means in the wrong place. An ectopic pregnancy occurs when the fertilised egg implants outside of the womb. Over 95% of ectopic pregnancies occur in the fallopian tubes.
If a fertilised egg implants itself in your fallopian tube, and continues to grow, it can result in miscarriage and there is a risk of the tube bursting. Signs of an ectopic pregnancy include pains low down in your stomach and vaginal bleeding.
If you are having fertility treatment, your chances of having an ectopic pregnancy are slightly increased, particularly if you have existing problems with your fallopian tubes.
Multiple pregnancy
Having more than one baby may not seem like a bad thing, but it does significantly increase the risk of developing complications for both you and your children. Multiple pregnancy can cause a woman's blood pressure to rise significantly. You are also two to three times more likely to develop diabetes during pregnancy compared with if you are carrying a single baby.
Around 50% of all twins and 90% of triplets are born prematurely, or with a low birth weight. The risk of your baby dying in the first week of life is five times higher for twins than for a single baby. For triplets this risk increases to nine times higher than for a single baby.
Stress
Infertility can be very stressful and put a lot of strain on relationships. It may be helpful for you to join a support group where you can talk through your feelings with other people experiencing similar problems. Finding out that you have a fertility problem can be traumatic, and many couples also find it helpful to talk to a counsellor. The counsellor can discuss treatment options with you, how they may affect you, and the emotional implications.
Preventing infertility
An important step in getting pregnant is making sure you are healthy, which you can do by making some simple lifestyle changes.
Diet
Make sure you eat a nutritious, balanced diet, containing plenty of fruit and vegetables, carbohydrates such as wholemeal bread and pasta, and lean meat, fish, and pulses for protein. Green, leafy vegetables are high in folic acid, which can help to prevent birth defects. Women who are either under, or overweight, also ovulate (release an egg) less regularly, or sometimes not at all. Ensuring you maintain a healthy weight will therefore make it much easier to conceive.
Supplements
The Department of Health recommends that women should take a daily supplement of 0.4mg of folic acid while they are trying to conceive. This helps to protect the unborn baby from problems such as spina bifida (when the baby's spine does not develop properly).
Lifestyle
It is very important to stop smoking if you are planning on getting pregnant. Smoking is linked to babies with a low birth weight.
Taking regular exercise helps you to maintain a healthy weight and beat stress.
The Department of Health recommends that women drink no alcohol while trying to conceive, as studies have shown that it can seriously damage a baby's development. If you do decide to drink during your pregnancy, limit your intake to one or two units of alcohol, once or twice a week, and avoid getting drunk.
Illegal drugs, such as marijuana or cocaine, can affect fertility, and can seriously damage the development of your baby should you fall pregnant. You should therefore avoid using them. You should also avoid using some prescription medicines if you are trying to get pregnant. Ask your GP for advice.
Health checks and tests - women
Make sure you are up-to-date with your cervical smear tests. You need to have one every three to five years depending on your age. You should also ask your GP for a blood test for anaemia, and visit your local sexual health clinic to make sure you do not have any sexually transmitted infections (STIs).
You can find your nearest clinic by visiting the Family Planning Association (FPA) website which allows you to search for your local clinic using your postcode. Infections, such as chlamydia, may not have any symptoms, but can cause infertility if left untreated.
It is important to be tested for rubella (German measles) before getting pregnant. You still need to be tested, even if you have previously had the vaccination. If there is a history of genetic conditions in your family, such as cystic fibrosis, or Down's syndrome, ask your GP about genetic testing.
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Infertility
