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Failure to conceive

Problems with fertility

Infertility is when a couple cannot conceive (get pregnant) despite having regular unprotected sex. It is not usual to investigate fertility until 12 months of trying to conceive. Around one in six or seven couples may have difficulty conceiving. This is approximately 3.5 million people. However, the number of couples who are actually infertile is low, around 5%.

Conceiving naturally 

About 85% of couples will conceive naturally within one year 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.

There are two types of infertility:

  • Primary infertility, where someone who has never conceived a child in the past has difficulty conceiving.
  • Secondary infertility, where a person has had one or more babies in the past, but is having difficulty conceiving again.

Deciding to seek help

It is a good idea for a couple to visit their GP if they have not conceived after one year of trying. Women over the age of 35, and anyone who is already aware that they may have fertility problems, should see their GP sooner. The GP may be able to check for common causes of fertility problems, and suggest treatments that could help. If fertility problems are diagnosed, there are many different treatments and procedures that are available.

Causes

Infertility can be caused by many different factors. Around a third of infertility is due to problems with the woman, and another third is due to problems with the man. In 23% of cases, a cause cannot be identified.

Problems with making eggs (ovulation) -
Infertility is most commonly caused by problems with ovulation (the monthly release of an egg). Some of these problems stop women releasing eggs at all, and some cause an egg to be released during some cycles, but not others. Ovulation problems can occur as a result of a number of conditions, listed below.
  • Polycystic Ovary Syndrome - a condition that makes it more difficult for your ovaries to produce an egg ( PCOS on website)
  • Thyroid problems - Both an overactive thyroid gland and an underactive thyroid gland can prevent ovulation.
  • Premature ovarian failure - where a woman’s ovaries stop working before she is 40. Luckily this is very rare.
Ovulation will be checked by blood tests e.g. day 2 FSH, day 21 progesterone and AntiMullerian Hormone, Sometimes you may be scanned throughout the cycle.

Womb and fallopian tubes - The fallopian tubes are the tubes along which an egg travels from the ovary to the womb. The egg is fertilised as it travels down the fallopian tubes. When it reaches the womb, it is implanted into the womb's lining where it continues to grow. If the womb or the fallopian tubes are damaged, or stop working, it may be very difficult to conceive naturally. These can be checked by an X-ray called a hysterosalpingogram or an operation called a Laparoscopy and Dye test. Your doctor should discuss the “pros and cons” of each.

Endometriosis - is a condition where small pieces of the womb lining, known as the endometrium, start growing in other places, such as in the fallopian tubes or the ovaries. This can cause infertility because the new growths form adhesions (sticky areas of tissue) or cysts (fluid-filled sacs) that can block or distort the pelvis. These make it difficult for an egg to be released and become implanted into the womb. Endometriosis can cause infertility because it can disturb the way that a follicle (fluid-filled space in which an egg develops) matures and releases an egg. Endometriosis can only be diagnosed by a laparoscopy (see endometriosis)

Pelvic inflammatory disease - is an infection of the upper female genital tract, which includes the womb, fallopian tubes, and ovaries. It is usually a sexually transmitted infection (STI). PID can damage and scar the fallopian tubes, making it virtually impossible for an egg to travel down into the womb. Damage to the tubes cab be assessed by the HSG or laparoscopy.

Submucosal fibroids - are benign (non-cancerous) tumours that grow in, or around, the womb. Submucosal fibroids develop in the muscle beneath the inner lining of the womb wall and grow into the middle of the womb. Submucosal fibroids can reduce fertility, although exactly how they do this is not yet known. It is possible that a fibroid may block one of your fallopian tubes, or prevent an egg from implanting itself into your womb. 

Sterilisation - Sterilisation involves blocking the fallopian tubes to make it impossible for an egg to travel to the womb. This process is rarely reversible, and if you do have a sterilisation reversed, it will not necessarily mean that you will become fertile again.

Age - Infertility in women is also linked to age. The biggest decrease in fertility begins during the mid thirties. For women who are 35, 95% will get pregnant after three years of having regular unprotected sex. For women who are 38, only 75% will get pregnant after three years of having regular unprotected sex.

Semen -
Abnormal semen (the fluid containing sperm that is ejaculated during sex) is the most common cause of male infertility. Abnormal semen accounts for 75% of male infertility cases. Some possible reasons for abnormal semen are listed below.
  • Decreased number of sperm. You may have a very low sperm count, or no sperm at all.
  • Decreased sperm mobility. If you have decreased sperm mobility, it will be harder for your sperm to swim to the egg.
  • Abnormal sperm. Sometimes sperm can be an abnormal shape, making it harder for them to move and fertilise an egg.
  • Many cases of abnormal semen are unexplained, but there are several factors that can affect semen and sperm.

Factors that affect both men and women

As well as factors that specifically affect a man or a woman’s fertility, there are also a number of factors that can affect fertility in both men and women. These are outlined below.

Weight -
Being overweight, or obese, reduces both male and female fertility. In women, being overweight can affect ovulation. Being underweight can also have an impact on fertility, particularly for women, who will not ovulate if they are severely underweight.

Smoking - As well as affecting your general and long-term health, smoking can also adversely affect fertility.

Occupational and environmental factors -
Exposure to certain pesticides, metals, and solvents can affect fertility in both men and women.

Stress - If either you or your partner is stressed, it may affect your relationship. Stress can reduce libido (sex drive) which in turn can reduce the frequency of sexual intercourse. Severe stress may also affect female ovulation and limit sperm production.

Medicines to assist fertility

If a cause is found you will be offered treatment options, depending on the diagnosis. The medicines that are often used to assist fertility are listed below.
  • Clomifene helps to encourage ovulation (the monthly release of an egg) in women who do not ovulate regularly or who cannot ovulate at all.
  • Metformin. You may have to take this if you have not responded to clomifene. It is particularly beneficial for women with polycystic ovaries  (PCOS) and a body mass index (BMI) of over 25.

Surgical

Fallopian tube surgery
If your fallopian tubes have become blocked or scarred, you may need to have surgery to repair the tubes. Surgery can be used to break up the scar tissue in your fallopian tubes, making it easier for eggs to pass along them. The success of the surgery will depend on how damaged your fallopian tubes are. Possible complications from tubal surgery include an ectopic pregnancy (when the fertilised egg implants outside of your womb).

Assisted conception

Intrauterine insemination (IUI) - Intrauterine insemination (IUI) involves sperm being placed into the womb through a fine plastic tube. Sperm is collected from the man and washed in a fluid. The best quality specimens (the fastest moving) are selected. The sperm are passed through a tube that enters the cervix and extends into the womb. This procedure is performed to coincide with ovulation in order to increase the chance of conception. The woman may also be given a low dose of ovary stimulating hormones in order to increase the likelihood of conception.
IUI tends to be used when:

  • Infertility cannot be explained.
  • The man has a low sperm count, or decreased sperm mobility.
  • The woman has mild endometriosis (where small pieces of the womb lining grow in other places).

Provided that the man's sperm and the woman's tubes are healthy, the success rate for IUI in women who are under 35 is around 15% for each cycle of treatment.

In-vitro fertilisation (IVF)
- During in-vitro fertilisation (IVF), the fertilisation of the egg occurs outside the body. The woman takes fertility medication to encourage her ovaries to produce more eggs than normal. Eggs are then removed from her ovaries and fertilised with sperm in a laboratory dish. The fertilised embryos are then put back inside the woman's body.

The success rate for a cycle of IVF is 29% for women who are under 35 years of age. The success rate decreases as the woman’s age increases. Check the success rates for your local clinics as they may vary widely.

Egg and sperm donation

If you or your partner has an infertility problem, you may be able to receive eggs or sperm from a donor to help you conceive. Treatment with donor eggs is usually carried out using IVF.

Anyone who registered to donate either eggs or sperm after 1 April 2005 can no longer remain anonymous, and has to provide information about their identity.

This is because a child born as a result of donated eggs or sperm is legally entitled to find out the identity of the donor upon reaching the age of 18.
Always ask your doctor if there is anything you do not understand.

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