Generally, over 8 in 10 couples having regular unprotected sex will conceive within one year if the woman is below 40 years. Among those couples who do not conceive in the first year, nearly half will succeed in the second year. About 1 in 7 couples may have trouble conceiving a baby
OVERVIEW OF FERTILIZATION AND PREGNANCY
A pregnancy results when an egg (or ovum) from the woman combines with a sperm from the man. An ovum is released from the woman’s ovary (ovulation) every month, usually between 12 and 16 days from the start of her last period if she has a regular cycle of 28-30 days. The ovum travels from the ovary down the Fallopian tube to the middle of the womb (uterus) over the next 12-24 hours.
The fertile period or the time when a woman has a good chance of becoming pregnant is for about 5 to 6 days in each cycle. Normally, the egg lives for about 1 day after ovulation, and sperm can remain viable in the womb for about 6 days after sex. Thus, a woman can usually become pregnant for around 6 days of every menstrual cycle, i.e., the 5 days before ovulation, and on the day of ovulation. Women hoping to conceive usually track their menstrual cycles for signs of ovulation, to try and become pregnant
CAUSES OF INFERTILITY
Infertility can result from various causes both in men and women. In about 30-40 percent of couples, a cause may be found in both partners. Some conditions are more easily treated than others. In about 25 percent of couples no cause can be identified
In general, older women have more difficulty in conceiving. Also stress in one or both partners may affect sexual drive or libido and fertility
INVESTIGATION OF INFERTILITY
Usually couples consult an obstetrician/gynecologist for assessment. You also may choose to see an infertility specialist (Ob-Gyn with special training in evaluating and treating infertility in women and men). They are also called reproductive endocrinologists. Men can be seen and treated by an urologist. Some urologists have special training in treating male infertility
Fertility tests take time and especially since female fertility decreases with age, it is best to make an early appointment. It is advisable for both partners to visit the doctor as fertility problems can affect either partner or sometimes both.
HISTORY
A detailed history is important including menstrual history, history of prior pregnancies, miscarriages, problems during sex, history of sexually transmitted infections, lifestyle, and medication history
PHYSICAL EXAMINATION
• Measurement of weight and body mass index (BMI) in both
• Pelvic examination to look for evidence of ovarian cysts, masses, or scar tissue in women
• Testicular and penis examination to look for any masses or abnormalities
LAB TESTS
• Semen analysis in the male partner is advisable initially to rule out any qualitative or quantitative defects of sperm and possible male cause for the infertility
• Serum progesterone level done on day 21 of a 28 day cycle to assess for ovulation
• Serum gonadotropin level measurement in women whose periods are irregular
• Tests to rule out thyroid disease and diabetes
• Tests to rule out chlamydial infection by cervical swab (women) or urine test (men)
• Ultrasound scan of pelvis to check for abnormalities in the uterus, tubes or ovaries
• Hysterosalpingography with contrast ultrasound or x-ray to assess for tubal blockages that may prevent the egg from reaching the womb
• Laparoscopy to directly visualize the pelvic organs and look for any obvious abnormalities
TREATMENT OF INFERTILITY
The three major forms of fertility treatment include
• Medicines
• Surgery
• Assisted conception – including intrauterine insemination (IUI) and in vitro fertilisation (IVF)
MEDICATIONS
Fertility medicines are given to women usually to help with ovulation problems. However, in some cases, they may also be given to men as well
Common fertility medicines include
• Clomiphene – encourages the monthly release of an egg (ovulation) in women having anovulatory cycles
• Tamoxifen – an alternative to clomiphene used in some women with ovulation problems
• Metformin – particularly useful for women with PCOS
• Gonadotrophins – help stimulate ovulation in women, and can also promote fertility in men
• Gonadotrophin-releasing hormone and dopamine agonists – other medication given to encourage ovulation
SURGICAL TREATMENT
• Surgery to repair scarring of fallopian tubes
• Laparoscopic surgery to destroy endometriosis lesions
• Surgery to remove endometrial uterine fibroids
• Laparoscopic drilling surgery to remove a portion of the ovary if medical treatment has failed
• Surgery to repair epididymal scarring that blocks normal sperm ejaculation in men
• Surgical extraction of sperm for storage and future use in men with no vas deferens or failed vasectomy reversal
ASSISTED CONCEPTION
Intrauterine insemination (IUI)
IUI or artificial insemination (AI) involves inserting sperm into the womb via a thin plastic tube inserted through the cervix. Sperm is first collected and rinsed in a fluid. The best-quality sperm are selected for AI.
In vitro fertilisation (IVF)
In IVF, the egg is fertilised outside the body. The woman is treated with fertility drugs to stimulate her ovaries to make more eggs than normal. Eggs taken from her ovaries are fertilised with sperm in a laboratory. The fertilised egg called an embryo is then placed in the woman's womb to develop into a baby
Intracytoplasmic Sperm Injection (ICSI)
This method involves a single sperm being injected directly into an egg and thus overcomes any natural barriers preventing fertilisation. ICSI is used for couples after failed IVF, or where the number or quality of sperm is too low for normal IVF to succeed
Egg or sperm donation
If either of the partners has an infertility problem, they can receive eggs or sperm from a donor to aid conception, usually done through IVF