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Understanding Fertility and Infertility

Fertility and Infertility

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.

Fertility

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

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.

Causes of infertility

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:

  • Ovulation problems
  • Structural problems (such as blocked fallopian tubes)
  • Sperm problems (abnormal sperm, low sperm count, absent sperm) Hormonal or other rare problems
  • A mixture of male and female problems
  • Unknown

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.

Lifestyle factors

Before couples rush off to doctors for investigations they should look at the various lifestyle factors that may be contributing to their problems conceiving:

  • Many couples lead busy and often stressful lives. Stress can be a cause of reduced fertility by interfering with ovulation if severe enough, but more significantly it can interfere with the frequency of sexual intercourse.
  • Less frequent intercourse will reduce your chance of getting pregnant. Remember at the very most you have twelve chances in a year to get pregnant.
  • Being very overweight, very underweight or undertaking excessive exercise can also contribute towards reduced fertility. 
  • Smoking and excessive drinking in both men and women can reduce fertility. Smoking in women leads to nicotine substances being secreted into the cervix and fallopian tubes and can have a toxic effect on sperm and potential embryos. Smoking and drinking in men reduces sperm count. High caffeine intake can also reduce sperm count in men
  • Certain occupations can reduce fertility such as working with certain chemicals. Men who sit down a lot in their job generate increased heat, which can reduce their sperm count.
  • Tight clothing for men can also reduce sperm count due to increased temperature. Replacing close fitting underwear with boxer shorts or tight jeans with lose pants may help

Other causes of infertility

Factors other than lifestyle that can cause infertility are:

  • Endometriosis, which manifests as painful periods and spotting before a period (this may occur in around 90% of endometriosis). 
  • Irregular periods mean ovulation will be irregular and of uncertain quality. Seek advice early from your doctor if this is the case with you. Don’t panic! Stress can also cause this
  • Infections like pelvic inflammatory disease and blocked fallopian tubes can also cause infertility.
  • Having babies late in life is significant as fertility in women declines sharply after the age of thirty-five. 
  • Low sperm counts or abnormally shaped sperm can cause infertility.

Secondary Infertility

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:

  • Trying to juggle motherhood and career can be stressful and reduced fertility by interfering with ovulation. A more likely side effect of stress is reduced sexual intercourse
  • If you are still breastfeeding this may also reduce your fertility, particularly in the first six months following the birth. 
  • Being overweight is a common problem after having a baby and it can reduce your fertility. Being very underweight or undertaking excessive exercise to get your pre-baby figure back can also contribute towards reduced fertility. 
  • Smoking and drinking in both men and women can reduce fertility. Having abstained all through the previous pregnancy you may have taken up old habits. 
  • Women who have had caesareans appear to have a subsequent reduction in fertility
  • Having already had one baby you may relax about your fertility and when you try to conceive again several years later you will naturally be older and less fertile.

Self help for infertility

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.

Investigating infertility

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: 

  • What is the quantity and quality of your partner’s sperm?
  • Are you ovulating and ovulating well?
  • Are your fallopian tubes patent?
  • Is the sperm getting to the right place at the right time for fertilisation to occur?

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. 

  • Male investigations particularly involve sperm analysis, medical examination and blood tests. The number, movement and shape of the sperm will be examined. Other factors examined will be antibodies and infections. Blood tests will estimate the level of different hormones in the man’s body.
  • Female investigations will involve determining if and when ovulation is occurring. The easiest way to do this is to take and record your temperature every morning on waking and before you get out of bed. A slight rise should occur at ovulation. You will be also be asked to document when you have had intercourse. Blood tests may be taken to determine whether or not you are ovulating. There are also now simple tests you can buy to help determine when you are ovulating and you can try these out before seeking professional help. If you are ovulating well and your partner’s sperm seems normal then you may have a laparoscopy to determine whether or not your fallopian tubes are blocked and your uterus looks normal.
  • Joint investigations involve both male and female factors being investigated together. One such test is to aspirate some mucous out of the cervical canal after intercourse when ovulation is expected. This is then examined under the microscope and the number of moving sperm is identified. 

Fertilisation methods

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:

  • Artificial insemination by the partner 
  • Artificial insemination by a donor
  • In vitro fertilisation (IVF). This is where the egg is fertilised by the sperm in a laboratory and placed back in the woman’s body. 
  • Gamete intra-fallopian transfer (GIFT). This is when the sperm and eggs are transferred directly into the fallopian tubes where fertilisation normally takes place. This involves a general anaesthetic and a laparoscopy. This is not done much now due to the high chance of having a multiple pregnancy (twins, triplets etc)
  • Ovum donation (eggs are donated by another woman) Ovulation induction (stimulates ovulation using hormones)

Success rates

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.

Psychological considerations

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.

 Dr Hannah Dahlen is the Associate Professor of Midwifery at the University of Western Sydney. She has been a midwife for more than 20 years. Hannah is also an executive member of the Australian College of Midwives, NSW Branch. She has researched women's birth experiences at home and in hospital and published extensively in this area. Hannah's website is www.hannahdahlen.com.au

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