Many of us take our fertility for granted. We presume that one day when we choose to we will be able to have a baby. We envisage one or two months of pleasurable ‘trying’ before pregnancy is achieved. This is not an unreasonable expectation considering the considerable lengths many of us go to in order to prevent pregnancy. The stories we hear from friends and family of unexpected pregnancies reinforce this faith we have in our fertility. Infertility therefore can come as a great shock and disappointment for couples who discover pregnancy will not occur easily for them.
Every month from the moment menstruation starts until a woman reaches menopause one, or occasionally more, eggs are released from her ovaries. This egg, called an ovum, moves down the fallopian tube where it may come into contact with sperm and be fertilised. Men can produce more than 300 million sperm in one ejaculation and these sperm are capable of moving through the woman’s cervical mucus, up through the cervix into her uterus and on into the fallopian tube.
Around 85% of couples will become pregnant within the first year of ‘trying’. Half of the remaining couples will get pregnant within two years and half of these remaining couples will get pregnant within three years of trying. The chances of getting pregnant decreases as women get older. Around ten years prior to the onset of menopause women start to get low on healthy eggs. This means a woman’s fertility drops fairly significantly around 38 to 40 years of age. This decline, however, can happen anywhere from 35 to 45 years of age. At the same time the rate of miscarriage increases with advancing age. In your early 20’s around 13% of pregnancies may end in miscarriage. In your early 30’s around 16% of pregnancies may end in miscarriage and by your early 40s almost 50% of pregnancies can end in miscarriage.
Men with normal sperm counts seem to remain capable of fertilisation at any age. There is, however, increasing evidence that their fertility also declines with age.
Infertility is generally defined as a situation where pregnancy is not achieved despite a year of unprotected sexual intercourse where a couple is trying to achieve a pregnancy. The incidence of infertility is estimated to be around 10-15% of all couples. The incidence is increasing due to the trend for women to leave motherhood until later on in life. Other factors such as busy couples having intercourse less frequently, declining sperm counts, sexually transmitted diseases and other harmful environmental factors play a part as well. Some specialists would argue that infertility is in fact nature’s way of spacing pregnancies in a highly evolved species such as ours.
Infertility is divided into primary infertility and secondary infertility. Primary infertility occurs where there has been no previous pregnancy whereas secondary infertility occurs where there has been a previous pregnancy. Many of the causes of these two types of infertility are, however, similar.
Infertility has many causes. Approximately one third of the cases of infertility are due to male factors, one third is due to female factors and one third is due to a combination of male and female factors. The main causes can be grouped into the following categories:
Causes of infertility can be further categorised into male and female factors. Both male and female factors can be involved, making the problem even more complex. What can be a minor infertility problem in a woman and a minor infertility problem in a man when taken together can be a major infertility problem.
It is a misconception that male factors play a minor role in infertility. Male factors account for up to 40% of the cases of infertility. There are controversial theories about whether sperm counts are actually dropping in many Western countries and whether lifestyle factors may be a factor in this. Men may have sperm that are immobile, abnormal, absent or low in number. While only one sperm is needed for fertilisation, you need many to travel up through the cervix into the uterus and then into the fallopian tube in order for that one successful sperm to fertilise the waiting ovum. If the sperm can’t move well or are an abnormal shape and unable to penetrate the ovum then fertilisation cannot occur. There are few medical treatments that can effectively improve fertility in men with these problems. There are, however, lifestyle factors that may help improve sperm counts.
Infertility factors in women are generally due to absent or reduced ovulation, blockage to the fallopian tubes or other structural abnormalities that don't allow implantation or growth of the baby in the uterus.
Before couples rush off to doctors for investigations they should look at the various lifestyle factors that may be contributing to their problems conceiving:
Factors other than lifestyle that can cause infertility are:
Secondary infertility is a term used to describe a group of women who have managed to get pregnant previously, often with no apparent problems, but are subsequently unable to get pregnant despite a year of unprotected intercourse.
Many of the factors already discussed can cause secondary infertility. Some additional factors to consider with secondary infertility are:
Try to concentrate sexual intercourse to your most fertile week which is 4 days before and 4 days after you expect to ovulate. You can work out when you ovulate by counting back 14 days before your period is due. You should also become familiar with the physiological signs of ovulation such as an increase in the amount and stretchiness of the vaginal mucous. Increased libido during ovulation is nature’s way of getting you and your partner together.
Optimal frequency of sexual intercourse is an area of great debate. Maximising sexual intercourse (every couple of days mid cycle) around the time of ovulation is of course ideal but restricting yourself at other times of the cycle to ‘save the sperm’ up is not necessary and indeed can reduce the motility.
Sperm form best at a temperature just below the body’s temperature, which is one reason why the testicles are outside the abdomen. Tight underwear can increase this temperature and reduce the sperm count. Getting your partner out of the Y fronts into the boxers and out of the tight jeans and into the lose pants might help improve his sperm count. Because it takes the sperm two to three months to form you will have to keep this up at least this long! Other factors that can influence sperm production are to do with certain occupations, such as professional drivers who are sitting down all the time causing an increased heat that restricts the manufacture of sperm.
If you have not fallen pregnant after a year of unprotected intercourse despite a change to significant lifestyle factors that influence fertility, then talk to your doctor. Your local doctor will refer you to a fertility expert who will investigate the possible cause. The main questions that will be asked and investigated will be:
You will both be asked detailed questions. You will be given a thorough medical examination and undergo several tests if this is necessary. Don’t be embarrassed if you are asked intimate questions about your sex life. Sometimes the problem is that intercourse is simply not happening frequently enough or at the right time or even the right way. A medical history or examination may reveal infections or relevant surgery. Lifestyle factors will also be looked at. Smoking, drinking and heavy coffee consumption may be some of the things you may be asked to alter. The woman will be asked detailed questions about her menstrual history, particularly its frequency and regularity. A history of a thyroid imbalance, pelvic inflammatory disease or certain surgery will also be taken.
Investigations can be divided into male investigations, female investigations and joint investigations.
For some couples changes in lifestyle and being made aware of fertile periods for intercourse can be sufficient for pregnancy to begin. Depending on the cause or causes of the infertility other fertilisation methods that you may need to consider are:
Success rates vary hugely depending on what is the cause of the infertility and how easy it is to rectify. Certainly the success rates have improved over the last few years and new techniques are developing every day. In Australia around 3000 to 4000 women a year are treated with IVF with an overall pregnancy rate of around 20% This varies between units. The success of IVF also declines significantly with increasing maternal age.
Couples undergoing investigations for infertility experience significant stress. Before physical investigations commence psychological issues need to be explored. Are both of the partners committed to having a child or is the pressure of family and friends the main cause of them seeking help. Seeking to have a child to help mend a poor relationship is a risky venture as fertility treatment can be very stressful and requires great commitment and support from each other.
Not only is there often family and societal pressures to start a family but also there may be years of disappointment to deal with. If the infertility problem is due to one partner there may be shame, anger and pressure to deal with. To start turning sexual intercourse into a purposeful anxiety ridden exercise can put enormous strain on a couple’s relationship. Couples need to try and maintain as much spontaneity as possible in their sexual relationships. Supporting each other and remembering it is your relationship that is most important is essential if the best results are to be realised. Never hesitate to seek counselling and professional support if the process is becoming destructive to your relationship or to you as a person.