Infertility can be defined as the inability to conceive by natural means. It can also refer to the biological inability to contribute to conception, or for a female being unable to carry a pregnancy to full term.

Who is at risk of infertility?

It has been estimated that infertility is currently affecting one out of six couples in Australia, however the causes of infertility can be down to a diverse number of reasons or combination of factors. For some it may be issues with the sperm or egg cells, the structure of the reproductive systems, hormone imbalances, or even immune conditions.

Age is also a contributing factor, as there is a rapid decline in fertility in women who are past their mid-30s. Men who are over the age of 35 are also thought to be only half as likely to successfully reproduce (1).

However, it has been estimated that the cause is unexplainable in one in four couples with infertility.

Assessment of fertility issues

Medically speaking, if a couple in their respective reproductive age groups have been actively trying to conceive for one year but have been unsuccessful, then they will be offered further clinical assessment and treatment options. Earlier referrals are usually available for couples when the woman is over the age of 36, or if the patients have a history of predisposing infertility factors.

Due to the aforementioned range of potential issues, it is critical to undertake appropriate investigations in order to get to the root of the problem and to potentially find a solution. The assessment stage could include semen analysis, ovulation assessment, checking for abnormalities in the uterus and tubes, and screening for sexually transmitted diseases.

A fertility specialist is usually in charge of assessing overall reproductive health. For women, this can involve something as simple as a blood test which will be able to check whether she is ovulating and producing eggs each month.

A second blood test is also available, which can measure Anti Mullerian Hormone (AMH). This hormone can act as an indication of ovarian reserves and how many eggs are available in the patient’s ovaries.

This allows for the healthcare professional to then check whether the results are considered normal for the patient in regards to their age.

Otherwise, an ultrasound scan may be carried out which can check the patient’s endometrium and see if there are any abnormalities which are distorting the lining of the womb.

Abnormalities can include any of the following (2):

• Fibroids or polyps which can affect the hormone levels and lead to irregular periods
• Ovarian cysts, which can affect the menstrual cycle
• The size of the ovaries and the quantity of small follicles

The ultrasound technician may also check how easy it is to take eggs from the ovary if required.

If the above assessments are inconclusive, then a doctor may advise checking the patency of the patient’s fallopian tubes via a sonohysterogram or a hysterosalpingogram.

For men, the most important and significant fertility test is a semen analysis. Male infertility can be a result of poor sperm production or transport. These can be down to a number of reasons including (2):

• Blocked or absent tubes
• Low or even non-existent sperm production, therefore a low sperm count
• Abnormalities in sperm cells
• The presence of anti-sperm antibodies
• Sperm DNA fragmentation – damaged sperm cells

A semen analysis will measure the quantity and quality of sperm, as well as their motility and the volume and consistency of the sample. The analysis is straightforward and some laboratories are able to analyse samples within one hour to avoid compromising the results.

Treatment of fertility issues

Once a patient has been diagnosed, treatment could fall into any of the three following categories (2):

• Medical treatment via the use of drugs to restore fertility (for example, when drugs are administered to induce ovulation)
• Surgical intervention to restore fertility (for example, in the case of endometriosis when laparoscopy is done for endometrial ablation)
• Assisted Reproduction Technology (ART). This can be defined as any technique which is used to achieve a viable pregnancy. Most commonly this will involve in vitro fertilisation (IVF) and artificial insemination.

One of the first treatment options involves tracking the ovulation cycle in order to help a couple find their fertile window in which they are most likely to conceive.

Failing this, the couple will be offered ovulation induction which encourages ovaries to release eggs. Medication in the form of a tablet or an injection can help to stimulate hormones, which will ultimately maximise the chances of conception through natural intercourse or artificial insemination.

Women will be monitored throughout the month with blood tests, medication, and ultrasound examinations to check for ovulation (2).

Most of the female fertility surgeries will involve minor keyhole surgery, which is also known as laparoscopy. Laparoscopy can help treat conditions such as endometriosis, tubal microsurgery, fibroid removal, and may even correct some minor abnormalities in the uterus. As a result of this surgery, many couples find they are able to conceive naturally once the patient has healed and resumes her normal menstrual cycle. However, if there are still complications, then IVF may have higher chances of success (2).

Men are offered microsurgeries for repair of small structures, such as the vas deferens tubes which carry the sperm. It can also be done to reverse vasectomies, cure varicoceles, or to retrieve sperm for assisted reproduction technology (2).

Artificial insemination will involve insertion of the sperm, either from the partner or from a donor sperm, through the cervix and directly into the uterus at the time of ovulation. The procedure is not painful and can be performed by a nurse. IVF will involve joining gametes in a laboratory and leaving the embryo to grow before it is transferred into the patient’s uterus. Again the actual procedure is simple and offers many couples the best chance of a successful pregnancy (2).


Sources:

NICE
IVFAustralia