85% will conceive within a year of regular unprotected sex. 1 in 7 couples will struggle to conceive naturally.
Investigation and referral for infertility should be initiated after the couple has been trying to conceive without success for 12 months. This can be reduced to 6 months if the woman is older than 35, as her ovarian stores are likely to be already reduced and time is more precious.
- Sperm problems (30%)
- Ovulation problems (25%)
- Tubal problems (15%)
- Uterine problems (10%)
- Unexplained (20%)
40% of infertile couples have a mix of male and female causes.
There is some general lifestyle advice for couples trying to get pregnant:
- The woman should be taking 400mcg folic acid daily
- Aim for a healthy BMI
- Avoid smoking and drinking excessive alcohol
- Reduce stress as this may negatively affect libido and the relationship
- Aim for intercourse every 2 – 3 days
- Avoid timing intercourse
Timed intercourse to coincide with ovulation is not necessary or recommended as it can lead to increased stress and pressure in the relationship.
Initial investigations, often performed in primary care:
- Body mass index (BMI) (low could indicate anovulation, high could indicate PCOS)
- Chlamydia screening
- Semen analysis
- Female hormonal testing (see below)
- Rubella immunity in the mother
Female hormone testing involves:
- Serum LH and FSH on day 2 to 5 of the cycle
- Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
- Anti-Mullerian hormone
- Thyroid function tests when symptoms are suggestive
- Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.
High LH may suggest polycystic ovarian syndrome (PCOS).
A rise in progesterone on day 21 indicates that ovulation has occurred, and the corpus luteum has formed and started secreting progesterone.
Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.
Further investigations, often performed in secondary care:
- Ultrasound pelvis to look for polycystic ovaries or any structural abnormalities in the uterus
- Hysterosalpingogram to look at the patency of the fallopian tubes
- Laparoscopy and dye test to look at the patency of the fallopian tubes, adhesions and endometriosis
A hysterosalpingogram is a type of scan used to assess the shape of the uterus and the patency of the fallopian tubes. Not only does it help with diagnosis, but it also has therapeutic benefit. It seems to increase the rate of conception without any other intervention. Tubal cannulation under xray guidance can be performed during the procedure to open up the tubes.
A small tube is inserted into the cervix. A contrast medium is injected through the tube and fills the uterine cavity and fallopian tubes. Xray images are taken, and the contrast shows up on the xray giving an outline of the uterus and tubes. If the dye does not fill one of the tubes, this will be seen on an xray and suggests a tubal obstruction.
There is a risk of infection with the procedure, and often antibiotics are given prophylactically for patients with dilated tubes or a history of pelvic infection. Screening for chlamydia and gonorrhoea should be done before the procedure.
Laparoscopy and Dye Test
The patient is admitted for laparoscopy. During the procedure, dye is injected into the uterus and should be seen entering the fallopian tubes and spilling out at the ends of the tubes. This will not be seen when there is tubal obstruction. During laparoscopy, the surgeon can also assess for endometriosis or pelvic adhesions and treat these.
Management of Anovulation
The options when anovulation is the cause of infertility include:
- Weight loss for overweight patients with PCOS can restore ovulation
- Clomifene may be used to stimulate ovulation
- Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
- Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
- Ovarian drilling may be used in polycystic ovarian syndrome
- Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.
Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.
Management of Tubal Factors
The options for women with alterations to the fallopian tubes that prevent the ovum from reaching the sperm and uterus include:
- Tubal cannulation during a hysterosalpingogram
- Laparoscopy to remove adhesions or endometriosis
- In vitro fertilisation (IVF)
Management of Uterine Factors
Surgery may be used to correct polyps, adhesions or structural abnormalities affecting fertility.
Management of Sperm Problems
Surgical sperm retrieval is used when there is a blockage somewhere along the vas deferens preventing sperm from reaching the ejaculated semen. A needle and syringe is used to collect sperm directly from the epididymis through the scrotum.
Surgical correction of an obstruction in the vas deferens may restore male fertility.
Intra-uterine insemination involves collecting and separating out high-quality sperm, then injecting them directly into the uterus to give them the best chance of success. It is unclear whether this is any better than normal intercourse.
Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg. These fertilised eggs become embryos, and are injected into the uterus of the woman. This is useful when there are significant motility issues, a very low sperm count and other issues with the sperm.
Donor insemination with sperm from a donor is another option for male factor infertility.
Last updated August 2020