What is infertility?
The desire to have a child is one of the most fundamental and powerful drives in humans. This does not mean that everyone, always wants to have children – in fact many people spend large parts of their life avoiding pregnancy for very good reasons! However, when individuals wish to have a child and this does not happen, this can cause great and profound unhappiness. This sadness can extend beyond the individual concerned to their partners and loved ones. Couples may need to revise their life-plans and learn to deal with a ‘child-shaped hole’ in their lives. Contrary to the opinions of bar-room philosophers and some parts of the tabloid media, infertility is a real and serious condition, and medical authorities world-wide recognise it as such.
The best definition of infertility that I know of is the one used by the American Society of Reproductive Medicine, which states
‘Infertility is a disease defined by the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse.’
I like this definition because it is a relatively precise way of deciding when a couple trying to have a baby should seek medical advice. Research tells us that as many as 1 in 7 couples may suffer from this problem and need advice or assistance.
Of course, the desire to have a child is not restricted to those in a relationship or to heterosexual people – single persons and same-sex couples can also have a powerful desire to have offspring.
What are the causes of infertility?
Investigations uncover a cause in roughly 8 out of 10 couples with infertility. This diagram, from the HFEA shows the distribution of causes of infertility among patients having fertility treatment in the UK in a typical year.
Broadly speaking in about 3 out of 10 couples a cause is found in the man alone and in another 3 out of 10 couples in the woman alone. Both male and female causes are found in roughly 2 out of 10 couples, while no cause can be ascertained in another 2 out of 10.
What tests are recommended if we have been trying to conceive without success?
I would always advise that couples speak to a professional in whose expertise they trust before doing any tests, so that they can be guided to what tests are best for them. In most cases, the doctor will take a history from both partners, trying to pick up on features that may have implications for your fertility, such as whether you have regular cycles or not, whether there has been any evidence of a pelvic infection (such as Chlamydia), whether one or both partners smokes etc. In most cases, the female partner should be examined by the doctor; the man may also need to be examined depending on his medical history.
As a first step, tests are carried out to check if the woman is ovulating and if her tubes are open. To this, in my practice, I add an assessment of the woman’s ovarian reserve. For ovulation, a simple blood test is carried out to measure levels of the hormone progesterone about 7 days before the expected date of the next period is carried out. I am often asked by patients how to time this test if their cycles are a bit irregular – the best course of action is to develop psychic powers, so you know exactly when your next period is going to start! Failing that, it is reasonable to do the test on a couple of occasions 5 to 7 days apart, in the second half of your menstrual cycle. Tests that you can buy at the chemists that measure LH in the urine are also helpful. The progesterone level in blood should be tested seven days after your first positive stick test.
Testing the fallopian tubes can be done by a number of methods, and the choice between these will depend on the features on your history and examination. In cases where there is no great fear that there is a problem with the tubes, a test called Hysterosalpingogram (HSG) is advised. This does not require anaesthesia and is carried out in the X-Ray department in the first 10 days of your cycle. It is advisable to take some paracetamol or Ibuprofen as pain relief 30 minutes before the test, as it can be uncomfortable.
In women where there are features that raise the suspicion of tubal problems or where we suspect endometriosis, a laparoscopy is usually advised. This is a procedure done under general anaesthetic. A small cut is made in your belly-button and a telescope is inserted into your tummy. A further cut is made lower down on the tummy to allow a device to be inserted that enables the surgeon to move the organs around and get a good view of the tubes, ovaries and womb.
A laparoscopy is specially useful in finding out if you have endometriosis, which can be associated with infertility and pelvic pain. Find out more about endometriosis and the treatments available by clicking here
Ovarian reserve testing is done by measuring the levels of a hormone in your blood called AMH (Anti-Mullerian Hormone) and by a an ultrasound scan to count the number of small follicles in your ovaries (Antral Follicle Count or AFC). These tests can be done at any time in your cycle. Simply put, AMH is a hormone produced by cells in your ovaries that surround the developing egg. As the woman ages, the number of eggs declines and so do the levels of AMH in her blood. By measuring the AMH level, we can tell whether a woman has an ‘average’ egg reserve for her age or not. This information is particularly helpful in women having IVF, as it helps plan their treatment. It is not known at present whether AMH or AFC predict whether a woman will conceive naturally – research is ongoing in this area, but it is a complex subject.
For men, the fertility test is less complicated. A sample of semen is examined in the laboratory and the scientist counts the number of sperm per ml of semen, the proportion of sperm that appear normal and the proportion that are swimming around actively. The result can be compared against the numbers we know are compatible with ‘normal’ fertility from research done on men whose partners conceived within 12 months of starting to try to conceive.
Can we do anything to boost our chances of conceiving?
There is a lot of interest in ‘lifestyle’ factors and fertility. Quite a bit is known from research regarding the impact of smoking and alcohol intake on fertility. We are also finding out more about matters such as exercise, body weight, the composition of your diet and drugs such as cannabis and anabolic steroids. For a presentation explaining the effect of lifestyle on fertility, click here. This is a presentation I did to the Irish Fertility Society in 2012 on this topic and is really directed at professionals, but in my experience most fertility patients actually have a very good understanding of these issues and should be able to follow the information in the presentation.
It might seem sometimes, that everything that is enjoyable in life, with the obvious exception of sex, is bad for your fertility! I think it is important not to set ridiculously high standards for yourself. Take time to relax and if the odd glass of wine should pass your lips, try not to worry too much about it. Infertility can be stressful enough, and you need to ensure you make some me-time and couple-time when you are not just focussing on procreation.