Infertility

Infertility is the word used when pregnancy does not happen after a year of regular sex without contraception. That year is not a verdict but a marker, the point at which it makes sense to start looking: within twelve months more than eight couples in ten conceive if the woman is under forty, and half of the rest manage it during the second year with no treatment at all. In roughly a third of cases the cause lies with the woman, in another third with the man, and in the remainder either with both at once or nowhere that can be identified. That is why both partners are always investigated, and why it is better to start together rather than one after the other.

How long to wait before seeing a doctor

The rule of thumb is simple and depends mainly on the woman's age.

• Under 35, a year of regular sex without contraception.
• From 35 onwards, six months: testing and treatment take months in themselves, and the ovarian reserve does not grow while you wait.
• From 40 onwards, do not wait at all.

Nor is there any reason to wait, at any age, when something is already known: absent or wildly irregular periods, a previous ectopic pregnancy, surgery on the womb or ovaries, pelvic inflammatory disease, a past chlamydia infection, endometriosis, chemotherapy or radiotherapy. For a man the same applies to surgery on the testicles, a past infection of the testicle, an undescended testicle in childhood and injury.

Having conceived before is no reason to put the visit off either: in what is called secondary infertility, acquired causes turn up more often, such as adhesions, infection, weight gained or a change in semen quality.

What stands in the way for a woman

Most often it is ovulation: the egg either does not come at all, or does not come every cycle. The cycle itself gives it away when it runs longer than 35 days or shorter than 21, arrives unpredictably or stops altogether. Behind it usually sits polycystic ovary syndrome, a thyroid disorder, a raised prolactin level, a very low body weight combined with hard training, or premature ovarian insufficiency, meaning ovaries that stop working before forty.

The second large group is the fallopian tubes. They are damaged by pelvic inflammatory disease, which most often follows a chlamydia infection that caused no symptoms whatsoever. That is exactly why a chlamydia test belongs to the first round of investigations even when there has never been a complaint. Tubes also suffer after pelvic surgery and after an ectopic pregnancy.

Then come endometriosis, in which tissue resembling the womb lining grows outside it and changes the anatomy of the pelvis; fibroids, when they distort the cavity of the womb; and adhesions inside the womb after a surgical procedure. And there is one cause that cannot be corrected: age. After 35 it is not only the number of eggs that falls but their quality, and no drug alters that.

What stands in the way for a man

Almost everything comes down to semen quality: too few sperm, sperm that move poorly, or sperm that are badly formed. In about half of cases the reason is never established, but it is worth looking, because some of the causes can be put right.

• Varicocele, a group of dilated veins around the testicle; it is the commonest finding and it can be treated.
• Damage to the testicle itself: past inflammation, including mumps caught in adulthood, injury, torsion, surgery, or a testicle that never descended into the scrotum in childhood.
• Blockage of the tubes carrying sperm, after infection, after surgery, after a vasectomy or from birth; in the last of these the man not uncommonly carries a mutation linked to cystic fibrosis, which is worth knowing before trying for a baby.
• Low testosterone. It may be driven by a pituitary tumour or by Klinefelter syndrome, an extra chromosome that many men live with unaware.
• Taking testosterone or anabolic steroids, perhaps the commonest reversible cause of all: hormone from outside switches off the body's own production and sperm disappear entirely. Recovery takes anywhere from a few months to a year and is not always complete, so tell the doctor plainly.
• Difficulty with erection or ejaculation, rarely connected in people's minds with infertility although the link is direct.

What you can change before any treatment

None of this replaces proper investigation, but it works for both partners and costs nothing.

• Weight. Obesity lowers the odds in women and worsens semen in men; being severely underweight stops ovulation altogether. What matters is not an ideal figure but movement in the right direction.
• Smoking, including other people's. It speeds up the loss of ovarian reserve and damages sperm, and it is one of the few factors on which the evidence is beyond argument.
• Alcohol. While you are trying to conceive the safest option is none at all; in men, heavy drinking noticeably lowers semen quality.
• Medicines. Long-term anti-inflammatory painkillers can suppress ovulation, sulfasalazine temporarily lowers the sperm count, and some psychiatric drugs raise prolactin. Do not stop anything on your own; ask about alternatives.
• How often you have sex. Every two or three days across the whole cycle is more reliable than trying to hit a single day. Ovulation tests and temperature charts add anxiety and almost nothing to the odds.
• Heat around the scrotum from saunas, heated car seats or a laptop on the lap. The effect is real but modest, and loose underwear works no miracles.
• Chemicals at work such as pesticides, solvents and heavy metals: if you are exposed to them, say so.

Stress belongs on this list with a caveat. It lowers desire and makes sex infrequent, and in severe cases it disturbs the cycle, but the advice to “just relax” is unfair, because blocked tubes and absent sperm are not explained that way.

What the tests look for

In a woman the first question is whether ovulation is happening: progesterone is measured in the second half of the cycle, and where periods are irregular the pituitary hormones, prolactin and thyroid function are added. Ovarian reserve is estimated from anti-Müllerian hormone and the follicle count on ultrasound, but the result has to be read correctly: it predicts the response to stimulation, not natural conception, and a low figure does not mean pregnancy is impossible. After that come a pelvic ultrasound, a chlamydia test and a check of the tubes, either by ultrasound with contrast or by an X-ray with contrast. Laparoscopy is kept for a specific suspicion, endometriosis being the usual one.

For a man the main test is semen analysis, and it is far easier to do at the outset than after a year of investigating his partner. One poor result on its own means nothing: sperm take around two and a half months to mature and any feverish illness spoils the sample for weeks, so the test is repeated. If the abnormality is confirmed, a urologist takes over with an examination, a scrotal ultrasound, hormone tests and, where the count is very low, genetic testing.

What can be offered

The choice follows the cause, and the range is wide.

• Where ovulation is absent, it is induced with tablets, and in polycystic ovary syndrome drugs that improve insulin sensitivity are added. The next step up is injected hormones with ultrasound monitoring.
• Surgery helps in endometriosis, in fibroids that distort the cavity of the womb, and in varicocele. Repairing damaged tubes is attempted rarely: the outcome depends on how badly they are scarred, and going straight to IVF is often the more sensible route.
• Intrauterine insemination, in which semen is placed directly into the womb; it is a simple procedure suited to mild abnormalities and to the use of donor sperm.
• In vitro fertilisation, where fertilisation happens outside the body. With a severe male factor a single sperm is injected into the egg under the microscope, and where there is no sperm at all in the ejaculate it can sometimes be retrieved from the testicular tissue itself.
• Donor eggs and donor sperm. The rules on donation, anonymity and patient age differ from country to country, and it is worth finding out how they stand where you are before you begin.

Some things are mentioned too rarely and are worth knowing. Ovarian stimulation can cause hyperstimulation syndrome: the abdomen becomes distended, weight climbs quickly and breathing becomes difficult. With those signs, contact the clinic immediately. Transferring several embryos raises the chance of twins and with it the risk of premature birth, which is why a single embryo is transferred more often nowadays. After IVF the risk of an ectopic pregnancy is slightly higher. And if chemotherapy or radiotherapy lies ahead, freezing sperm or eggs is something to raise before treatment starts, not afterwards.

What does not work: supplements sold “for fertility”, herbal mixtures and acupuncture have no convincing evidence behind them, and drugs that stimulate the ovary do not improve the odds in unexplained infertility when ovulation is already normal.

When “it isn't happening” is a symptom of something else

Sometimes infertility is not a diagnosis but the first sign of a condition that needs treating in its own right. Do not delay if any of the following appears:

• milk leaking from the breast outside breastfeeding, particularly alongside headaches or loss of the outer field of vision, which is how a pituitary tumour announces itself;
• periods stopping before forty with hot flushes and night sweats, since premature ovarian insufficiency affects not only fertility but bone and arteries as well;
• a lump felt in a testicle, or a testicle that changes size or feels heavy: testicular cancer is often picked up precisely during an infertility work-up, and the earlier it is found the better it responds;
• lower abdominal pain with discharge and fever, because acute pelvic infection is treated urgently and every day lost adds scarring to the tubes;
• severe pain with periods and during sex, bad enough to force changes to everyday life, which is the classic picture of endometriosis and is typically diagnosed years late.

Online consultation

The first step is the murkiest one, and it works well remotely: deciding whether it is time to be investigated and where to begin, so that six months are not lost doing tests in the wrong order. The doctor goes through the cycle and the history of both partners, says which investigations make sense in your particular situation and on which day of the cycle to have them done, and helps you read results you already hold, semen analysis included, which is hard to interpret alone. It is also an unhurried way to review the medicines you take and to ask the questions that are awkward to say out loud. The signs listed above, and any suspicion of ovarian hyperstimulation, are not dealt with remotely: those need to be seen in person.

This material is for information only and does not replace medical advice.