Infertility can be defined as difficulty in achieving pregnancy after one year of frequent, unprotected intercourse. Evaluation generally begins after 12 months, but can be initiated earlier if infertility is suspected based on history or if the female partner is older than 35 year.
In order to conceive, a women needs to be ovulating regularly, while the man needs to have healthy sperm. They also need to be having intercourse at the right time in the woman’s monthly cycle, so that sperm is ready to fertilize the egg when it is released. Sometimes the issues that cause infertility in couples are present at birth, and sometimes they develop later in life.
Infertility factors affect one or both partners. In general, about one-third of cases are due to male factors, one-third of cases due to female factors and in the remaining cases, there are issues with both the male and female, or no cause can be found. A careful history and physical examination of each partner can suggest a single or multifactorial etiology and can direct further investigation and subsequent treatment to help the couple achieve a successful pregnancy.
There are several risk factors for infertility including:
- Older age
- Excessive alcohol consumption
- Being underweight or overweight
- Lack of exercise or excessive strenuous exercise
Causes of male infertility include:
- Lifestyle — smoking, obesity, alcohol consumption, use of recreational drugs or anabolic steroids.
- Abnormal sperm production or function due to undescended testicles, genetic defects (Klinefelter syndrome), androgen insensitivity, varicocele, infections such as STD (Chlamydia and gonorrhoea), mumps and HIV, testicular torsion
- Problem with the delivery of sperm such as premature ejaculation, erectile dysfunction (ED), structural problems such as blockage in the testis or damage to the reproductive organs from previous surgery, trauma, scarring from STD infection or cancer treatment
- Medical health disorders such as autoimmune diseases, diabetes and thyroid disease and medications such as blood pressure medications, Sulfasalazine (for treatment of inflammatory bowel disease) and antidepressants
- Psychological disorders such as extreme stress, depression and anxiety
- Unexplained causes
Causes of female infertility:
- Advanced age
- Ovulatory dysfunctions which affect the release of eggs from the ovaries due to polycystic ovarian syndrome (PCOS), high prolactin (hyperprolactinaemia), thyroid disease, too much exercise and excessive weight loss from eating disorder
- Pelvic diseases such as tubal occlusion from STD infection, endometriosis, fibroids, adenomyosis, polyps, ovarian cyst, scarring from previous surgery (Asherman Syndrome)
- Premature ovarian failure when the ovaries stop working and menstruation ends before the age of 40 years such as in certain genetic conditions like Turner’s Syndrome, autoimmune system disorder, medication such as chemotherapy and unknown cause (idiopathic)
- Pelvic cancer, cancer treatments such as radiation and chemotherapy
- Lifestyle — smoking, obesity, alcohol consumption, use of recreational drugs, excessive caffeine intake.
- Unexplained causes
Work-up of infertility required detailed menstrual history, frequency of sexual intercourse, and complete intercourse, medical, surgical and medical history. This includes past obstetric and gynecological information and social history. Investigations for female infertility include full hormonal profile work-up including testosterone level (for polycystic ovarian syndrome/PCOS), thyroid function test and day 21 progesterone (to evaluate ovulation), STD screening, ultrasound pelvis and hysterosalpingography to assess tubal patency. Investigations for male infertility includes hormonal profile, seminal fluid analysis, STD screening and ultrasound of testes.
In 10–15% of couples, a specific cause for their infertility is not found. A diagnosis of unexplained cause is made once other causes of infertility have been ruled out from the investigations of both couples. Infertility treatment depends on the underlying cause. Fertility medication can be given to induce ovulation such as Clomiphene citrate, Metformin, Letrozole and Dopamine agonist. Non-pharmacological treatment includes assisted reproductive treatment such as intrauterine insemination (IUI), in-vitro fertilization (IVF) and intracytoplasmic sperm insemination (ICSI).
Couples are also advised on ideal coital frequency and keeping track of the “fertile window” which includes the five days preceding and the day of anticipated ovulation to improve chance of conception. Both partners should be encouraged to stop smoking, avoid alcohol consumption and recreational drugs and for women to limit caffeine intake. Both partners are encouraged to practice a healthy lifestyle and exercise regularly.
Infertility can cause significant physical, psychological and emotional stress to any couple looking to start a family. It is important to get an assessment early and talk to a medical professional about your fertility concern.