Infertility

Infertility and conception rates

Infertility is defined as the inability to conceive a pregnancy after 12 months of unprotected sexual intercourse. Infertility is a very common problem that affects about 15% of our community. To be successful at achieving a pregnancy several factors are required; the main ones being ovulation (regularly releasing an egg), patent (open) fallopian tube(s) and good quality sperm. A problem with one of these factors is likely to reduce fertility and it is not uncommon for couples to present with a problem in two or more of these areas. In general, 85% of couples will achieve a pregnancy in the first 12 months of unprotected intercourse and another 10% will achieve a pregnancy after a further year. Throughout the western world there has been a progressive increase in the average age of women having their first baby. The above figures are significantly affected by advancing female age, with a steady decline in fertility potential after the age of 35, and a steep fall off in pregnancy rates after the age of 40.

Common causes of infertility

Common causes of infertility are male (sperm) factor, disorders of ovulation including polycystic ovaries, disease of the fallopian tubes, endometriosis or a combination of female and male factors. In a high proportion of cases (perhaps 20-30%) no cause can be found, and this situation is termed "unexplained" or idiopathic infertility.

Investigation(s)

Following a detailed history and a physical examination, several tests can be performed to determine if cause(s) can be found and what is a couple's likelihood of becoming pregnant without treatment. These investigations include a semen analysis for men and blood (hormone) tests for women. Furthermore, it is usually important to investigate a woman's reproductive (pelvic) organs to exclude disease/blockage of the fallopian tubes, abnormalities of the uterus, endometriosis and/or scar tissue (adhesions).

Depending upon the situation, this can include a pelvic examination, an x-ray called a hysterosalpingogram (dye test), a specialized ultrasound examination called a sono-hysterogram, a hysteroscopy (telescopic examination of the inside of the uterus) and/or keyhole surgery (laparoscopy). Based upon what these investigation(s) show, further tests may be required to determine if there is an underlying condition (for example polycystic ovarian syndrome), what treatment option(s) are possible, and which option is likely to be the best approach to treatment.

Treatment(s)

Treatment is based upon whether a problem has been detected or the situation is unexplained, the nature of the problem, the woman's age, and the couple's preference having been informed about their test results and the merits and risks of all of their option(s). If there is a problem with ovulation, medication can be used to encourage/induce egg production, the main potential complication to be aware of being the increased risk of multiple pregnancy associated with the use of such medications. In certain situations insemination with your partner's or a donor's sperm may be indicated, where prepared sperm is inserted into the woman's uterus around the time of ovulation. Fertility surgery (usually via a laparoscope or hysteroscope /keyhole surgery) can be used to treat endometriosis, some types of blockage of the fallopian tubes, or correct abnormalities of the uterus. Open microsurgery can be used for reversal of sterilization and some very severe cases of endometriosis and/or adhesions (scar tissue).

Some couples will not require in-vitro fertilization (IVF) and will respond to less complex treatments or even conceive without treatment. However, IVF is the only treatment that does not require a women to have functional fallopian tubes, can be very successful in treating a wide range of fertility problems such as unexplained infertility, and with the use of sperm microinjection (ICSI) is very effective at treating male infertility problems. The decision whether to proceed to IVF or try more simple treatment(s) first, will depend upon many factors such as the woman's age, the type and severity of the problem, success rates of alternative treatments, and a couple's preference having been fully appraised of their test results, the likely chance of pregnancy without treatment, and the benefits, cost and risk(s) of available/alternative treatments.

Overview and developing a plan

If you have not been successful in achieving a pregnancy after twelve months of intercourse without using contraception, then this is a good time to discuss the situation with your doctor. However, in a number of circumstances referral to a Fertility Specialist before twelve months can be indicated, such as where the woman's periods are irregular or absent, the woman is aged 35 or older, there are other symptoms such as pelvic pain, there is a past history of a pelvic infection, there are problems with making love/achieving ejaculation into the vagina, or there has been a vasectomy or female sterilization in the past. A small number of specialists (gynaecolgists) have undergone three years' additional training in the management of infertility, have passed rigorous examinations and have obtained the additional qualification of CREI. These "subspecialists" have a very high level of expertise in managing fertility care.