Primary Infertility

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Infertility is when a couple cannot get pregnant (conceive) despite having regular unprotected intercourse. 

Around 1 in 7 couples may have difficulty conceiving. 

Getting help 

Some people get pregnant quickly, but for others it can take longer. It’s a good idea to go and see the GP after a year of trying to conceive.

Women aged 36 and over, and anyone who's already aware they may have fertility problems, should see their GP sooner. They can check for common causes of infertility and suggest treatments that could help. 

There are 2 types of infertility: 

  • Primary infertility: Someone who has never conceived a child in the past and has difficulty conceiving 

  • Secondary infertility: Someone has had 1 or more pregnancies in the past, but is having difficulty conceiving again 

What causes infertility? 

There are many possible causes of infertility and fertility problems can affect either partner. 

Common causes of infertility include: 

  • Lack of regular ovulation (the monthly release of an egg) 

  • Poor quality semen 

  • Blocked or damaged fallopian tubes 

  • Endometriosis – where tissue that behaves like the lining of the womb (the endometrium) is found outside the woman

In a quarter of cases it is not possible to identify the cause. This is known as unexplained infertility.

Risk factors 

There are also several factors that can affect fertility. 

These include: 

  • Age – fertility declines with age 

  • Weight – being overweight or obese (having a BMI of 30 or over) reduces fertility. In women, being overweight or severely underweight can affect ovulation 

  • Sexually transmitted infections (STIs) – several STI’s, including chlamydia, can affect fertility 

  • Smoking – (including passive smoking) affects your chance of conceiving and can reduce semen quality

  • Alcohol – the safest approach is not to drink alcohol at all to keep risks to your baby to a minimum. Drinking too much alcohol can also affect sperm quality. The chief medical officers for the UK recommend adults should drink no more than 14 units of alcohol a week, which should be spread evenly over 3 days or more 

  • Environmental factors – exposure to certain pesticides, solvents and metals has been shown to affect fertility, particularly in men 

  • Stress– can affect your relationship with your partner and cause a loss of sex drive. In severe cases, stress may also affect ovulation and sperm production 

There's no evidence to suggest caffeinated drinks, such as tea, coffee and colas, are associated with fertility problems. 

Infertility in women 

Infertility in women is commonly caused by problems with ovulation (the monthly release of an egg from the ovaries). 

Some problems stop an egg being released at all, while others prevent an egg being released during some cycles but not others. 

Ovulation problems can be a result of:  

  • Polycystic ovaries (PCOS)

  • Thyroid problems – both an overactive thyroid gland and an underactive thyroid gland can prevent ovulation 

  • Premature ovarian failure – where the ovaries stop working before the age of 40 

  • Scarring from surgery - pelvic surgery can damage and scar the fallopian tubes that link the ovaries to the womb. This scar tissue can block the pathway of the egg travelling to the uterus, affecting fertilisation and implantation. Cervical surgery can also sometimes cause scarring or shorten the neck of the womb (the cervix). 

  • Cervical mucus problems - when you're ovulating, mucus in your cervix becomes thinner so sperm can swim through it more easily. If there's a problem with the mucus, it can make it harder to conceive. 

  • Fibroids - Non-cancerous growths called fibroids in or around the womb can affect fertility. In some cases, they may prevent a fertilised egg attaching itself in the womb, or they may block a fallopian tube. 

  • Endometriosis - a condition where small pieces of the womb lining (the endometrium) start growing in other places, such as the ovaries. This can damage the ovaries or fallopian tubes and cause fertility problems. 

  • Pelvic inflammatory disease (PID) - is an infection of the upper female genital tract, which includes the womb, fallopian tubes and ovaries. It's often caused by a sexually transmitted disease (STI). PID can damage and scar the fallopian tubes, making it difficult or impossible for an egg to travel down into the womb. 

  • Medicines and drugs- side effects of some types of medicines and drugs can affect your fertility.

    These include: 

    Non-steroidal anti-inflammatory drugs (NSAIDSs) - long-term use or a high dosage of NSAIDs, such as ibuprofen or asprin, can make it more difficult to conceive 

    Medicines used for chemotherapy - can sometimes cause ovarian failure, which means your ovaries will no longer be able to function properly. Neuroleptic medicines – antipsychotic medicines, often used to treat psychosis, can sometimes cause missed periods or infertility.

    Spironolactone – a type of medicine used to treat fluid retention (oedema); fertility should recover around 2 months after you stop taking spironolactone

    Illegal drugs - such as marijuana and cocaine, can seriously affect fertility and make ovulation more difficult. 

Infertility in Men

A common cause of infertility in men is poor-quality semen, the fluid containing sperm that's ejaculated during sex. 

Possible reasons for abnormal semen include: 

  • A lack of sperm – you may have a very low sperm count or no sperm at all 

  • Sperm that are not moving properly – this will make it harder for sperm to swim to the egg 

  • Abnormal sperm – sperm can sometimes be an abnormal shape, making it harder for them to move and fertilise an egg. Many cases of abnormal semen are unexplained. 

  • There's a link between increased temperature of the scrotum and reduced semen quality, but it's uncertain whether wearing loose-fitting underwear improves fertility.  

  • Testicles - The testicles produce and store sperm. If they're damaged, it can seriously affect the quality of your semen.

     This can happen as a result of: an infection of your testicles, testicular cancer, testicular surgery , a problem with your testicles you were born with (a congenital defect) , when 1 or both testicles has not descended into the scrotum (the loose sac of skin that contains your testicles (undescended testicles) , injury to your testicles 

  • Ejaculation disorders - Some men experience ejaculation problems that can make it difficult for them to release semen during sex (ejaculate). 

  • Hypogonadism - Hypogonadism is an abnormally low level of testosterone, the male sex hormone involved in making sperm. It could be caused by a tumour, taking illegal drugs, or Klinefelter syndrome (a rare syndrome involving an extra female chromosome). 

  • Medicines and drugs - Certain types of medicines can sometimes cause infertility problems.

    These include:  Sulfasalazine – an anti-inflammatory medicine used to treat conditions such as Crohn’s disease and rheumatoid arthritis; sulfasalazine can decrease the number of sperm, but its effects are temporary and your sperm count should return to normal when you stop taking it  Anabolic steroids – are often used illegally to build muscle and improve athletic performance; long-term abuse of anabolic steroids can reduce sperm count and sperm mobility  Chemotherapy– medicines used in chemotherapy can sometimes severely reduce sperm production  Herbal remedies – some herbal remedies, such as root extracts of the Chinese herb Tripterygium wilfordii, can affect the production of sperm or reduce the size of your testicles  Illegal drugs - such as marijuana and cocaine, can also affect semen quality. 

Unexplained infertility

In the UK, unexplained infertility accounts for around 1 in 4 cases of infertility. This is when no cause can be identified in either partner. 

If a cause for your fertility problems has not been found, talk to your doctor about the next steps. 

The National Institute for Health and Care Excellence (NICE) recommends that women with unexplained infertility who have not conceived after 2 years of having regular unprotected sex and no prior children should be offered IVF treatment on the NHS. 

More than 8 in 10 couples, where the woman is under 40, will conceive naturally within a year of having regular unprotected sex. This means having sexual intercourse every 2 to 3 days without using contraception. 

When to get medical help 

See your GP if you have not conceived after a year of trying. 

You should see a GP sooner if: 

  • you are female and are aged 36 or over – the decline in fertility speeds up when reaching your mid-30s 

  • have any other reason to be concerned about your fertility, for example, if you've had treatment for cancer or you think you might have a STI

Fertility tests can take time and female fertility decreases with age, so it's best not to delay your investigations. 

The GP will be able to do an initial assessment to check for things that may be causing your fertility problems and advise you about what to do next. It's always best for both partners to visit the GP as fertility problems can affect either or both partners. 

Trying to conceive can be an emotional process, so it's important to try and support each other as much as possible.  If you find you are struggling emotionally, it is recommended to reach out for professional emotional support.

Questions your doctor may ask

  • The GP will discuss any medical conditions you have or had in the past, including STI’s. If you're a woman, the GP may ask if you have regular periods and whether you experience any bleeding between periods or after sex. 

  • The GP will ask how long you've been trying to conceive. About 84% of people will conceive within 1 year if they have regular unprotected sex (every 2 to 3 days). Of those who do not conceive in the first year, about half will conceive in the second year. If you're under 40 and have not been trying for a baby for very long, you may be advised to keep trying for a little longer. 

  • You'll be asked how often you have sexual intercourse and whether you have any difficulties during sex. You may feel uncomfortable or embarrassed discussing your intimate life with the GP, but it's best to be open and honest. If the fertility problem is related to sexual activity, it might be overcome easily. 

  • If you're a woman, the GP will discuss any previous births and any complications with previous pregnancies. They'll also ask about any miscarriages you've had. If you're a man, you'll be asked whether you've had any children from previous relationships. 

  • Some medicines can affect your fertility. The GP will ask you about any medicine you're taking and might discuss alternative treatments with you. You should mention any non-prescription medicine you're taking, including herbal remedies and supplements.

  • Several lifestyle factors can affect your fertility. The GP will want to know: 

    • if you smoke 

    • how much you weigh 

    • how much alcohol you drink 

    • whether you take any illegal drugs 

    • if you are feeling stressed 

    They may recommend making changes to your lifestyle to increase your chances of conceiving. 

Fertility Tests for Women

If you are female, the GP may:

  • weigh you to see if you have a healthy body mass index (BMI)

  • examine your pelvic area to check for infection, lumps or tenderness

    After a physical examination, you may be referred to a specialist infertility team at an NHS hospital or fertility clinic for further tests as described below

Blood tests Samples of your blood can be tested for a hormone called progesterone to check whether you're ovulating. 

The timing of the test is based on how regular your period are. 

If you have irregular periods you'll be offered a test to measure hormones called gonadotrophins, which stimulate the ovaries to produce eggs. 

Chlamydia test  Chlamydia is an STI that can affect fertility. A swab – similar to a cotton bud, but smaller, soft and rounded – is used to collect some cells from your cervix to test for chlamydia. A urine test may be used as an alternative. You'll be prescribed antibiotics if you have chlamydia. 

Ultrasound scan  An ultrasound scan can be used to check your ovaries, womb (uterus) and fallopian tubes. Certain conditions that can affect the womb, such as endometriosis and fibroids, can prevent pregnancy.  A scan can also be used to look for signs that your fallopian tubes (the tubes that connect the ovaries and the womb) may be blocked, which may be stopping eggs from travelling along the tubes and into the womb.  If the ultrasound suggests a possible blockage, your doctor will refer you to a specialist to discuss further checks, such as a laparoscopy. 

A hysterosalpingo-contrast-ultrasonography is a special type of ultrasound scan sometimes used to check the fallopian tubes. A small amount of fluid is injected into your womb through a tube put into the neck of your womb (the cervix). If the test suggests a possible blockage, your doctor will refer you to a specialist to discuss further checks, such as laparoscopy. 

Hysteroscopy A procedure used to examine the inside of the womb (uterus). It's carried out using a hysteroscope, which is a narrow telescope with a light and camera at the end. Images are sent to a monitor so your doctor or specialist nurse can see inside your womb. The hysteroscope is passed into your womb through your vagina and cervix (entrance to the womb), which means no cuts need to be made in your skin.

It is usually used for:

A procedure called dilatation and curettage (D&C) used to be common to examine the womb and remove abnormal growths, but now hysteroscopies are carried out instead.

Laparoscopy  Laparoscopy (keyhole surgery) involves making a small cut in your lower tummy so a thin tube with a camera at the end (a laparoscope) can be inserted to examine your womb, fallopian tubes and ovaries. Dye may be injected into your fallopian tubes through your cervix to highlight any blockages in them. 

Laparoscopy is usually only used if it's likely that you have a problem – for example, if you've had an episode of PID in the past, or if scans suggest a possible blockage of one or both of your tubes. 

X-ray  A hysterosalpingogram is an x-ray of your womb and fallopian tubes after a special dye has been injected. It can be used to find blockages in your fallopian tubes, which may be stopping eggs travelling along the tubes and into your womb. 

Fertility Tests for Men

If you are male, the GP may check your:

  • testicles to look for any lumps or deformities

  • penis to look at its shape, structure and any obvious abnormalities

After a physical examination, you may be referred to a specialist infertility team at an NHS hospital or fertility clinic for further tests.

Semen analysis  This is to check for problems with sperm, such as a low sperm count or sperm that are not moving properly. 

DNA Fragmentation Sperm DNA damage testing is a non-invasive procedure performed on a semen sample, usually before treatment as an additional diagnostic test.

Chlamydia test  A sample of your urine will be tested to check for chlamydia as it can affect fertility. Your GP will prescribe antibiotics if you have chlamydia.

Treating infertility 

Fertility treatments can vary and depend on the underlying issue diagnosed.

Treatments can include: 

  • medical treatment for anovulation (when regular ovulation is not occurring naturally)

  • surgical procedures; such as treatment for endometriosis, repair of the fallopian tubes, or removal of scarring (adhesions) within the womb or abdominal cavity 

  • assisted conception such as intrauterine insemination (IUI) or In Vitro Fertilisation (IVF) 

The treatment offered will depend on what's causing the fertility problems and what's available locally for you. 

Private treatment is also available, but it can be expensive. 

It's important to choose a private clinic carefully. You can ask a GP for advice and should make sure you choose a clinic that's licensed by the Human Fertilisation and Embryology Authority (HFEA). 

There is a chance that treatments for infertility, such as IVF, can cause complications, for example: 

  • multiple pregnancy – if more than 1 embryo is placed in the womb as part of IVF treatment there's an increased chance of having twins; this may not seem like a bad thing, but it significantly increases the risk of complications for you and your babies 

  • ectopic pregnancy – the risk of having an ectopic pregnancy is slightly increased if you have IVF 

To learn more about the different types of fertility treatments click below

Eligibility for fertility treatment on the NHS 

Fertility treatment funded by the NHS varies across the UK. Waiting lists for treatment can be very long in some areas. The eligibility criteria can also vary. A GP will be able to advise about your eligibility for treatment. If the GP refers you to a specialist for further tests, the NHS will pay for this. All patients have the right to be referred to an NHS clinic for the initial investigation. 

Going private 

If you have an infertility problem, you may want to consider private treatment. This can be expensive, and there's no guarantee of success. 

It's important to choose a private clinic carefully. You should find out: 

  • which clinics are available 

  • which treatments are offered 

  • the success rates of treatments 

  • the length of the waiting list 

  • the costs 

Ask for a personalised, fully costed treatment plan that explains exactly what's included, such as fees, scans and any necessary medicine. 

Choosing a clinic 

If you decide to go private, you can ask a GP for advice. Make sure you choose a clinic licensed by the HFEA.  

The HFEA is a government organisation that regulates and inspects all UK clinics that provide fertility treatment, including the storage of eggs, sperm or embryos. 

Complementary therapy 

There's no evidence to suggest complementary therapies for fertility problems are effective. 

The National Institute for Health and Care Excellence (NICE) states further research is needed before such interventions can be recommended. 

 

Reference- https://www.nhs.uk/conditions/infertility/ 

The above content is for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your GP or Doctor if you have any questions regarding your health.