Fertility

Infertility is when a couple cannot conceive despite having regular unprotected sex. Around one in six or seven couples may have difficulty conceiving. However, the number of couples who are actually infertile is low at around 5%. About 85% of couples will conceive naturally within one year and 95% within two years if they have regular unprotected sex. A couple will only be diagnosed as being infertile if they have not managed to have a baby after two years of trying. Women over the age of 35, and anyone who is already aware that they may have fertility problems, should seek medical advice sooner.

Infertility can be caused by many different factors. About one third of infertility is due to problems in the female, another third is due to male factors, and in 30%, a cause cannot be identified.

OVULATION DISORDERS

Infertility, in women, is most commonly caused by disorders of ovulation, either irregular or absent ovulation. This includes premature ovarian failure, where the ovaries cease to ovulate before age of 40 and polycystic ovary syndrome (PCOS), a condition of the ovary that makes ovulation difficult. Women with thyroid disorders (both underactive and overactive thyroid gland) also have irregular ovulation.

UTERINE AND ENDOMETRIAL DISORDERS

A fertilised ovum needs a healthy uterine lining to embed and develop. If the uterine lining (endometrium) is abnormal, as it may be when there is a fibroid or an endometrial polyp, then the fertilised ovum will be unable to implant and grow into an ongoing pregnancy. The endometrial lining may also not be very healthy when the uterus is of an abnormal shape such as a bicornuate uterus. Although studies have not convincingly proved the association between fertility problems and endometrial polps or a submucous fibroid, most women prefer to have these abnormalities corrected to improve their chances of a successful pregnancy.

TUBAL DISORDERS

Fallopian tubes are thin elongated structures extending from the ovary to the uterus on each side. The ovum (egg) is fertilised by the sperm as it travels down the fallopian tubes, and when it reaches the uterus, it implants on to the lining where it continues to grow. If the fallopian tubes are damaged or blocked, it may become difficult to conceive naturally. This can occur after pelvic surgery which may cause damage and adhesions to the fallopian tubes. Endometriosis can also cause infertility as the adhesions or cysts may obstruct or distort the tubes and ovaries making it difficult for an egg to be released and transported to the uterus for implantation. Pelvic inflammatory disease (PID) is an infection of the upper female genital tract including the endometrial lining and fallopian tubes with resulting damage to the fallopian tubes and failure of transport of the ovum.

To find the cause for fertility problems, a full medical, sexual and social history is taken followed by investigations including blood tests.

INVESTIGATIONS

Semen analysis

Semen analysis is the only test for the male partner. A sample is examined for volume, count, motility and morphology.

All other investigations are done in the female partner.

Serum Progesterone

This is a blood test done on the 21st day of menstrual cycle for progesterone levels. Levels of 30 nmol/l or higher indicate ovulation.

Day 2 LH/FSH

Luteinising Hormone (LH) and Follicle Stimulating Hormone (FSH) levels are checked on the 2nd or 3rd day of periods, and alteration of the ratio can indicate polycystic ovarian syndrome. Elevated FSH levels may indicate ovarian failure.

Thyroid function tests

It is estimated that between 1.5 to 5.1 percent of infertile women have an abnormal thyroid function, and testing for it is an important part of the infertility workup.

Prolactin

Elevated prolactin levels may be associated with lack of ovulation.

AMH (Anti Mullerian Hormone)

A check of blood AMH levels gives an indication of ovarian reserve and fertility in the woman.

Test for Chlamydia

Chlamydia is a sexually transmitted infection (STI) that can affect fertility. A swab is taken from the cervix to test for infection, and if positive for chlamydia, antibiotics are prescribed for treatment.

Pelvic Ultrasound

Transvaginal ultrasound looks at the uterus and ovaries. Polycystic ovaries may be detected on ultrasound which when associated with abnormal LH/FSH ratio and other symptoms is called Polycystic Ovarian Syndrome. An ultrasound assessment may also detect ovarian cysts or an endometrial polyp which may be an underlying cause for not conceiving.

OVULATION INDUCTION

Clomiphene

Is an ovulation inducing medication taken orally for 5 days in the beginning of a menstrual cycle to encourage ovulation (the monthly release of an egg) in women who do not ovulate regularly.

Metformin

Metformin is being increasingly used for induction of ovulation, and is thought to be particularly beneficial for women with polycystic ovary syndrome (PCOS) and a body mass index (BMI) of over 25.

Gonadotrophins

Gonadotropins are injectable agents to stimulate ovulation where clomiphene has been ineffective, and the growth of follicle should be monitored by ultrasound.

HYSTEROSCOPY AND LAPAROSCOPY

It may become necessary to obtain maximum information and also to treat certain conditions by surgical procedures like hysteroscopy and laparoscopy.

Hysteroscopy can detect and treat endometrial polyps in the uterine lining which may interfere with implantation of the embryo. This is treated by a procedure called transcervical resection of endometrial polyp. An ultrasound may identify a fibroid that protrudes into the uterine avity, called a submucous fibroid. This can also interfere with the implantation and development of an embryo. A submucous fibroid is treated by a hysteroscopic procedure called transcervical resection of fibroid (TCRF). Surgical removal of a polyp or fibroid may help in improving outcomes.

Laparoscopy can detect and assess tubal function. A laparoscopy can detect the state of the fallopian tubes if they are healthy. Where fallopian tubes have been involved in inflammation or endometriosis, they may appear swollen, congested and scarred. Laparoscopic dye test is when fluid mixed with a blue dye is injected into the uterine cavity through the cervix and the dye should fill both fallopian tubes and spill through the tubal ends. When the dye is seen to come out of the tube, it indicates that the tube is patent and not blocked.

Laparoscopy can detect ovarian cysts, endometriosis, and adhesions. Laparoscopic surgery will treat ovarian cysts, endometriosis and release adhesions. Where polycystic ovaries do not respond to medical management, then laparoscopic drilling may become necessary, although it should not be the first line of treatment.

ASSISTED CONCEPTION

Some women do not respond to the above measures and need referral to an IVF unit. For more information, please visit the Human Fertilisation and Embryology Authority (HFEA) website.