Infertility

What is infertility?

Infertility is a reproductive system condition preventing people from conceiving a child. This condition can affect everyone and has multiple causes.

Achieving a pregnancy involves a number of steps:

• Production of the reproductive hormones regulating ovarian function by the brain
• Maturing of the egg in the ovary
• Release of the egg from the ovary (ovulation)
• The fallopian tube picks up the egg
• Travel of the sperm up to the vagina via the uterus to the fallopian tube
• Fertilization of the egg by the sperm to form an embryo
• Movement of the embryo through the fallopian tube towards the uterus, where implantation takes place

If any of these steps fail to take place, then pregnancy cannot happen.

For individuals below 35, infertility may be diagnosed after a year (12 months) of attempting to conceive. Typically, trying to get pregnant means engaging in regular, unprotected sexual intercourse. The diagnosis of infertility in those who are 35 years or above may come after 6 months of having regular, unprotected sex.

Contrary to what most people think, infertility is more prevalent. However, the good news is that there are numerous available treatment options for those looking to start or grow their family.

What are the types of infertility?

Infertility can be classified into different types:

• Primary infertility: This is when you have never conceived and cannot get pregnant after a year of regular, unprotected sex (or 6 months if you are 35 years or above).
• Secondary infertility: This is when you cannot conceive again after you’ve had a previous successful pregnancy.
• Unexplained infertility: In this case, fertility testing does not identify the reason why you and your partner cannot have a child.

How common is infertility?

Infertilityis equally common among men and persons assigned male at birth (AMAB) as well as women and those assigned female at birth (AFAB). It is a widespread issue, and about 1 out of 5 women aged 15 to 49 experience primary infertility in the United States, while nearly 1 in 20 women are dealing with secondary infertility. Globally, around 48 million couples struggle with infertility.

Symptoms and Causes

What are the signs of infertility?

The inability to conceive after a year or 6 months of regular, unprotected intercourse is the primary sign of infertility. While most people may not exhibit additional symptoms, some may notice physical signs, like:

• Pain in the abdomen or pelvic
• Irregular periods, irregular vaginal bleeding, or absent periods
• Penile disorders or problems with ejaculation

What causes infertility?

Infertility can occur due to various reasons. At times, one cannot even understand why they aren’t conceiving, and only doctors can help pinpoint the exact cause and suggest a suitable treatment.

Infertility causes can widely vary; however, studies indicate that:

• 33 percent of infertility cases involve a woman with ovaries and uterus
• 33 percent involve a man with a penis and testicles
• 33 percent involve both partners or remain unexplained

In addition, 25% of couples struggling with infertility have multiple contributing factors.

Infertility causes

Certain infertility causes can only affect one partner, whereas some affect both. Common risk factors linked to infertility are:

• Age, especially for those in their late 30s or 40s; fertility normally declines around age 50 in men.
• Eating disorders such as anorexia nervosa and bulimia
• Too much alcohol intake
• Being exposed to environmental toxins like chemicals, pesticides, and lead
• Over-exercising
• Chemotherapy or radiation therapy
• Sexually transmitted infections (STIs)
• Smoking and use of tobacco products, which contribute to nearly 13% to 15% of all cases of infertility
• Substance misuse
• Obesity or being underweight
• Hormone-releasing centres abnormalities (hypothalamus or pituitary gland)
• Chronic disorders

Infertility causes for women and people AFAB

Ovulation problems are the leading reason for infertility among individuals with ovaries. Ovulation is when an ovary releases an egg to be fertilized by the sperm.

Factors that may be contributing to female infertility are:

• Endometriosis
• Structural defects of the uterus, vagina, or fallopian tubes
• Autoimmune disorders, including lupus or celiac disease
• Kidney disease
• Pelvic inflammatory disease (PID)
• Pituitary glands and hypothalamic disorders
• Polycystic ovary syndrome (PCOS)
• Primary ovarian insufficiency (poor egg quality)
• Sickle cell anaemia
• Uterine fibroids or polyps
• Thyroid disease
• Previous surgical sterilization (salpingectomy or tubal ligation)
• Inherited or chromosomal conditions
• Sexual dysfunction
• Absence of ovaries at birth or through surgery
• Absent or irregular menstrual periods

Infertility causes for men and people AMAB

The leading cause of male infertility in men mostly involves issues with sperm shape, movement (or motility), or quantity (low sperm count).

Additional causes may include:

• Enlarged veins (varicocele) in the scrotum (the sac holding the testicles)
• Genetic conditions like cystic fibrosis
• Chromosomal disorders like Klinefelter syndrome
• Exposing the testicles to high heat by wearing tight clothing, regularly using hot tubs and saunas, and placing laptops or heating pads near the testes
• Scrotal or testicle injury
• Reduced testosterone (hypogonadism)
• Anabolic steroids misuse
• Sexual dysfunction, including erectile dysfunction, premature ejaculation, anejaculation, or retrograde ejaculation
• Undescended testicles
• Priorradiation therapy or chemotherapy
• Surgical or congenital absence of testes
• Previous surgical sterilization (vasectomy)

Diagnosis and Tests

How is female infertility diagnosed?

To diagnose infertility, the doctor will begin by obtaining your complete medical and sexual history.

Usually, fertility in individuals with a uterus entails the ovulation of healthy eggs. For this to happen, the brain must transmit hormonal signals to the ovary to allow the egg to travel to the uterine lining through the fallopian tube. Fertility tests aim to find any problems involving these steps.

The following tests can be used to detect or rule out some issues:

• Pelvic exam: A pelvic exam is performed to look for structural disorders or signs of an illness.
• Blood test: A blood test measures hormone levels to check whether hormonal imbalances are the reason or confirm ovulation.
• Transvaginal ultrasound: This involves inserting an ultrasound wand into the vagina to examine the reproductive system for any problems.
• Hysteroscopy: During this test, a thin, illuminated tube (hysteroscope) is inserted into the vagina to inspect the uterus.
• Saline sonohysterogram (SIS): This involves filling the uterus with saline (sterilized salt water) and performing a transvaginal ultrasound.
• Sono hysterosalpingogram (HSG): This involves filling the fallopian tubes with air bubbles and saline while conducting SIS to look for blockages in the tubes.
• X-ray hysterosalpingogram (HSG): During this procedure, X-rays are used to track an injectable dye as it moves through the fallopian tubes to detect blockages.
• Laparoscopy: A laparoscope (a tiny tube equipped with a camera) is inserted through a small abdominal incision to detect conditions like uterine fibroids, endometriosis, or scar tissue.

How is male infertility diagnosed?

Infertility diagnosis in individuals with a penis generally involves ensuring that healthy sperm are ejaculated. Many fertility tests focus on identifying issues with sperm.

These diagnostic tests can be used to detect or rule out problems associated with male infertility:

• Semen analysis: Doctors use this test to examine the low count and poor motility of the sperm. Sometimes, a needle biopsy is necessary to extract sperm directly from the testicles for analysis.
• Blood test: Blood tests measure the level of thyroid and other hormones and can include genetic tests to assess chromosomal abnormalities.
• Scrotal ultrasound: An ultrasound of the scrotum can detect varicoceles or other issues with the testicles.

Treatment and Management

How is infertility treated?

Infertility treatment varies mainly based on the underlying cause and individual goals. Factors that determine the treatment choices are age, duration of attempting to conceive, and personal preferences. Depending on the situation, one or sometimes both partners may require treatment.

Mostly, individuals and couples struggling with infertility have increased odds of conceiving, thanks to medicines, surgeries and assisted reproductive technology (ART). In addition, lifestyle adjustments or enhancing the regularity and timing of sex can raise the chances of getting pregnant. Infertility treatment can as well involve a combination of methods.

Infertility treatment for women

For women and persons AFAB, infertility treatment options include:

• Lifestyle changes: Adding or cutting weight, quitting smoking or drug use, and addressing other health problems can enhance the chances of getting pregnant.
• Medications: Fertility medications prompt the ovaries to release more eggs, hence increasing the likelihood of conceiving.
• Surgery: Surgical procedures can be done to unblock fallopian tubes and take out fibroids, polyps, or scarred tissue.

The doctor may also recommend strategies to help improve the chances of conception, such as:

• Tracking ovulation using basal body temperature, fertility tracking applications, and monitoring cervical mucus texture.
• Getting a home ovulation kit at a drug shop or buying it online to track ovulation.

Infertility treatment for men

For men and people AMAB, treatment options are:

• Medications: Drugs can help increase testosterone and other hormone levels. Medications for erectile dysfunction to maintain an erection during intercourse are also available.
• Surgery: A surgical procedure to unblock the sperm-carrying tubes or correct structural issues is necessary for some men. Varicocele surgery can help boost sperm health and improve conception chances.

What are the common fertility treatment options?

For some couples, assisted reproductive technology (ART) is necessary for conception. ART refers to any form of fertility treatment whereby the doctor handles the sperm or eggs. In order to boost the chances of pregnancy, medications may be recommended to help stimulate ovulation before attempting one of these methods:

• In vitro fertilization (IVF): During IVF, eggs are retrieved from the ovary and placed together with sperm in a lab dish for fertilization to occur. 1 to 3 fertilized eggs (embryos) are then transferred to the uterus.
• Intracytoplasmic sperm injection (ICSI): During IVF, the embryologist can perform this procedure by directly injecting a single sperm into each egg. After that, one to three embryos are transferred to the uterus.
• Intrauterine insemination (IUI): This procedure involves directly placing sperm into the uterus using a long, tiny tube. IUI is also referred to as artificial insemination.
• Assisted hatching: The embryo’s outer layer is opened during this process to facilitate its implantation in the uterine lining.
• Third-party ART: Sometimes, couples opt to use donor eggs, sperm, or embryos, and some may also require a gestational carrier or surrogate.

What are the complications of treatments?

Complications associated with infertility treatment include:

• High possibility of having multiples: Multiple egg production and transfer of more than one embryo raise the risk of getting pregnant with multiple foetuses (twins, triplets, or more). This can lead to complications, like miscarriage, low birth weight, premature birth, neonatal death, or long-term medical problems.
• Ovarian hyperstimulation syndrome (OHSS): This condition results from fertility medications and leads to painful, swollen ovaries. OHSS can be severe and demand prompt medical care.
• Ectopic pregnancy: IVF increases the possibility of having an ectopic pregnancy.
• Failed cycles: This occurs when infertility treatment does not result in pregnancy.

Can infertility be cured?

Yes. Infertility is treatable, depending on its cause. Lifestyle changes, drugs, assisted reproductive technology (ART), or surgery can effectively treat infertility and enable conception in about 85 to 90 percent of all cases.

Prevention

How can I prevent infertility?

To protect your fertility, particularly when attempting to get pregnant, the following steps are recommendable:

• Eating a well-balanced diet and maintaining a healthy weight.
• Avoiding smoking, misusing drugs, or drinking alcohol.
• Seeking treatment for STIs.
• Limiting environmental toxins exposure.
• Being physically active but avoiding over-exercising.
• Avoid delaying conception till an advanced age.
• Opting for fertility preservation methods (freezing sperm or eggs).

Outlook/Prognosis

What can I expect if I have infertility?

Nearly 9 in 10 couples conceive after receiving fertility treatments. Usually, the success rates differ based on the reason for infertility, age, as well as other factors.

Infertility can have emotional, physical, psychological, or financial impacts. It’s thus important to be patient and practice self-care all through the process. Also, consider being around supportive individuals or join an online support group. Sharing your emotions with those who understand your situation can be very helpful at times.

Living With

Does insurance cover infertility treatment?

Health insurance coverage often varies by policy; hence, it is important to confirm with your insurance provider. Many insurers usually cover medically essential procedures, including surgeries to address problems like uterine fibroids and endometriosis. Some insurance policies can insure fertility treatment procedures such as intrauterine insemination but might not cover in vitro fertilization or ovulation-stimulating medicines.

Particular nations have laws requiring employers to have infertility insurance as part of the employees’ health coverage. According to the National Infertility Association (Resolve) reports, as of June 2022, twenty states have established laws pertaining to fertility insurance policies, of which 14 include IVF coverage. Twelve countries have laws relating to fertility preservation for cases of iatrogenic (medically induced) infertility.

For people living or working in a state where there is legislation for infertility insurance, it’s important to speak with your employer to find out the specifics of your coverage.

When should you seek help for infertility?

Individuals below 35 years who don’t conceive after a year of regular unprotected sex should consult a doctor. If you are between the ages of 35 and 39, it’s important to seek assistance sooner after trying for 6 months. Those aged 40 or above should also consider assessment after less than 6 months of attempting to conceive.

The odds of becoming pregnant reduce as a person ages. For instance, a female aged 25 years have a 25 to 30 percent chance of conceiving in every menstrual cycle. However, the probabilities become less than 5 percent per cycle by the age of 40.

Irrespective of gender, it’s advisable to find help sooner if you have a risk factor or health condition affecting fertility. In general, immediate assessment is necessary if one has a history of serious endometriosis, premature ovarian failure, or suspected or identified uterine/tubal disorder.

Gynaecologists and primary caregivers may refer couples to a fertility expert, urologist, or reproductive endocrinologist for further evaluation and treatment.

What questions should I ask my healthcare provider?

Consider asking your doctor the following questions:

• Should I consult a fertility specialist?
• Do my partner and I need to undergo testing for fertility problems?
• Depending on my age and partner’s, how soon do we need to get checked for fertility problems?
• Which treatment option is the best for us?
• What is the success rate of the treatment?
• What are the risks or side effects associated with the treatment?
• Should I keep an eye out for complications signs?