Infertility: the facts, causes and treatments
One in six couples experiences difficulty conceiving, but advances in medical techniques mean that many of the causes can be rectified
Failing to get pregnant after two years of regular unprotected sex is classed as infertility, according to the National Institute for Clinical Excellence (NICE). However, it’s advisable to visit your doctor after one year of trying, as 85% of couples conceive naturally within this time. And if a couple has specific worries about fertility or the woman is over 35, it is wise to go sooner. Female fertility decreases significantly with age and investigating fertility can be a lengthy process, so it makes sense to start as soon as possible if problems are suspected.
A woman’s fertility begins to decline many years prior to menopause, even though she will continue to menstruate normally. Every woman is born with all the eggs she will ever have, and at puberty most women have a staggering 400,000 eggs in their ovaries. For every egg that matures and develops during a menstrual cycle, 500 to 1,000 do not develop and are reabsorbed by the body.
And as a woman ages, so do her remaining eggs, rendering them less capable of being fertilised and developing into normal embryos. The fertility of most women peaks in their 20s, gradually starting to decline in their late 20s, and after 35 this decline begins to speed up. Indeed, a woman’s chance of getting pregnant in any month at age 30 is around 20%, but by 40 it is just 5%. Recent studies have shown that male fertility is also affected by age as sperm become increasingly sluggish from the late 30s onwards. Also, the quality of sperm is affected by a man’s age, resulting in a higher risk of miscarriage if he’s 40 plus.
Common causes of infertility in women
Weight. Being overweight or obese can affect ovulation and therefore reduce fertility. Equally, being underweight can also have an impact on fertility, particularly if the condition is so severe it has stopped the woman ovulating entirely.
Anovulation. A condition in which the ovary does not release an egg each month, anovulation is a prime factor in infertility. Irregular or short cycles, scant, erratic periods or the absence of menstruation entirely are usually the biggest indicator that anovulation may be the problem. This can be the result of hormone imbalances, diet or stress.
Blocked fallopian tube. Even if ovulation is occurring normally, a blockage in one or both of the fallopian tubes can prevent sperm from reaching the egg.
Hormonal imbalances. Any sort of hormonal imbalance can affect fertility. Most often, it will cause anovulation, but it can also affect the lining of the uterus and that in turn will prevent a fertilised egg from implanting.
Polycystic Ovarian Syndrome (PCOS). Women with PCOS have higher than average levels of testosterone and luteinising hormone and this hormonal imbalance causes irregular cycles.
Endometriosis. This is the presence and growth of endometrial tissue in places other than the uterus. One of the more common places for this tissue to grow is on the ovaries. It can cause damage, which may result in infertility.
If, after discussion and examination, it is decided that medically assisted conception is the best option, there are two general courses of action.
Firstly, when sperm is good and the woman’s reproductive structure is working correctly, ovarian stimulating medication is often administered. Clomiphene has been used for this purpose for many years.
It is taken as a tablet and it works by blocking a ‘feedback’ mechanism to the pituitary gland. This results in the pituitary making and releasing more gonadotrophin hormones than normal. The extra amount of these hormones in the blood stimulate the ovaries, which hopefully may result in ovulation. Medicines that actually contain gonadotrophins are another type of treatment. These need to be injected and tend to be used when clomiphene does not work, or prior to IUI and IVF to cause ovulation.
Gonadotrophin medicines may also improve fertility in men with certain types of hormone problems that can affect sperm count.
Metformin (which is more commonly used to treat diabetes) may be offered to women with PCOS who are infertile and have not responded to clomiphene.
If fertility medicine doesn’t have the desired affect, the best option for many couples is more invasive, medically assisted conception.
There are several types of treatment available and your doctor will explain which one would be most suitable for you to have the best chance of a successful pregnancy.
The first stage is for you to be referred to a specialist infertility team at an NHS hospital or fertility clinic for further tests and to fill in certain paperwork, including completing a form to apply for funding. One, and possibly up to three, cycles of treatment are usually available for free on the NHS providing patients meet the specific criteria of their local clinical commissioning group (CCG).
Reasons for refusal may include being over a certain age, having an unhealthy body mass index (BMI), or the fact that either you or your partner already has children.
Once funding has been agreed (which usually takes up to six weeks) you can arrange an appointment to begin…
Intrauterine insemination (IUI). This relatively straightforward procedure is when a doctor introduces sperm into the uterus by passing a fine plastic tube through the cervix. Sperm are then passed through the tube in the same way.
It is used for women who are still ovulating and it can be timed to coincide with ovulation, which is generally about halfway through a monthly cycle. Fertility medicines may also be given beforehand to maximise the chance of ovulation occurring. Women who have this procedure need to have healthy fallopian tubes to allow the egg to travel from the ovary into the uterus.
If successful, fertilisation takes place within the uterus, just like it would in a natural pregnancy.
In vitro fertilisation (IVF). IVF is an infertility treatment that’s used when there is a problem with the passage of the sperm to the egg. This can be caused by blocked fallopian tubes, endometriosis, anti-sperm antibodies, impaired sperm function and some cases of ‘unexplained’ infertility.
In vitro fertilisation means fertilisation outside of the body and in vitro literally means ‘in glass’
– that is, in a laboratory dish or test tube. IVF involves taking fertility medicines to stimulate the ovaries to make more eggs than usual.
When the eggs have formed, a small operation is needed to gather them: the ‘egg retrieval’ stage. This procedure is carried out under mild sedation and takes up to 20 minutes.
Each egg is mixed with sperm and left in a laboratory dish for a few days, giving the sperm time to fertilise the eggs to form embryos. One or two embryos which have formed are then placed in the woman’s uterus, once again by passing a fine plastic tube through the cervix. Any other embryos that have formed in the dish are either discarded or sometimes frozen to be used for further attempts at IVF.
Although most primary care trusts in the UK currently offer only one cycle of IVF free on the NHS, many couples need three complete cycles in order to have a realistic chance of conceiving. Some clinics may offer a ‘package’ of treatment.
Gamete intrafallopian transfer (GIFT). For this procedure, eggs and sperm are collected in the same way as for IVF and then the eggs are mixed with sperm. The risks – reactions to drugs and multiple births – are also similar.
The difference between this procedure and IVF is that this mixture of eggs and sperm are then placed into one of the woman’s fallopian tubes and the sperm fertilises the egg ‘naturally’ inside
the woman’s body rather than outside in a laboratory dish.
GIFT has been used in cases of ‘unexplained fertility’ or when the male partner is experiencing infertility problems. But this method has not been proven to be any more effective than IVF and so is not so commonly used nowadays.
Intracytoplasmic sperm injection (ICSI). This technique involves an individual sperm being injected directly into an egg and is often used when the sperm is not able to penetrate the outer part of the egg to fertilise. It is particularly useful when a male partner has a low sperm count because only one individual sperm is needed.
This one sperm will be injected into the cytoplasm (the outer part of the egg), thereby bypassing any natural barriers that may have been preventing fertilisation.
Egg donation. This method is an option for women who cannot produce eggs, who may have had their ovaries removed or suffer a condition where the ovaries do not work – for example, Turner syndrome. It is also an option for women when there is a high risk of transmitting a genetic disorder to the baby.
Essentially it requires a donor: a person who is willing to donate her healthy eggs. So donor eggs will be collected and mixed with the sperm of the partner of the woman who wants to become pregnant. After two or three days fertilisation will hopefully have taken place and the embryos can be placed in her uterus ready to grow into the baby she so wants.
When the NHS won’t pay…
Reviewing your options if you don’t meet the criteria for IVF treatment on the state or want to get started on the process without any six-week delay Perhaps you’ve had your permitted free IVF treatment and it didn’t work. Or maybe the NHS refused you on the grounds you were too old or overweight or – and this particularly affects couples in second relationships – one or both of you already has a child. Whatever the circumstances, don’t despair; you can always ‘go private’ – but you’d be wise to be guided by your GP as to where. Facilities and staff at private hospitals are often excellent – the Assisted Conception Unit at Guy’s and St Thomas (www.ivfdirect.com), for instance, is state-of-the-art. But private IVF treatment anywhere in the UK is going to cost you at least £3,000 and success can never be guaranteed.
at home guest editor, Dr Christian Jessen says… ‘Fertility – or rather the lack of it – is something that touches everyone, but many people don’t start thinking seriously about the topic until it is almost too late.’
Words: Georgina Maric Image: Shutterstock