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Infertility

From the moment we hit adolescence we begin to learn about reproduction, and not just the how, but also the why. We are taught about the worth and sense of fulfilment that can come hand in hand with having a family, so naturally we grow up believing that when the time comes for us to create are own descendants (if of course we wish to), we will be able to do so.

But what if the time comes and we are unable to conceive?

Infertility has been a source of sadness and despair since the earliest times, with stories of the emotional and social struggles of being unable to reproduce even appearing in the Old Testament.

Feeling that your body is suddenly working against you can be a very painful realisation, and on top of this you may then also be expected to make extremely difficult decisions regarding your future. Should you try again? Or is it time to start thinking of other ways to start a family?

So what is infertility? Infertility by definition, is a difficulty in conceiving despite having regular unprotected sex. There is no definitive cut off period after which a medical professional is able to say a couple is ‘infertile’, though statistics do suggest that the probability of a couple who have been trying to fall pregnant naturally for more than three years with no success is 25% or less.

Infertility statistics

According to NHS statistics, about one in six or seven couples may experience difficulties when trying to conceive, which means that around 3,500,000 are affected by the condition in UK.

However, whilst the number of individuals who experience problems is high, only 5% of the above figure are actually infertile. Statistics show that for every 100 couples attempting to fall pregnant naturally by having regular unprotected sex:

  • 20 will fall pregnant within one month
  • 70 will fall pregnant within six months
  • 85 will fall pregnant within one year
  • 90 will fall pregnant within 18 months
  • 95 will fall pregnant within two years.

*These values are cumulative

Although the statistics are encouraging, and increasingly better investigations and treatment mean that many individuals are able to overcome their fertility issues, for others, infertility often leads to isolation, loneliness and unfortunately a breakdown in relationships.

Infertility causes

There is no one definitive factor which causes infertility. According to the NHS, approximately one third of fertility problems are due to issues with the female, one third are down to problems with the male, and in up to 23% of circumstances doctors are unable to pinpoint a cause.

Infertility in women

Ovulation is vital to pregnancy, and without the monthly release of an egg there will be nothing for the male sperm to combine with. Failure to ovulate for whatever reason, is one of the most common causes of infertility and can occur as a result of a number of conditions:

  • Polycystic ovary syndrome (PCOS)
    This is a condition that often inhibits the ovaries from producing an egg.
  • Early menopause (POI)
    A women’s ovaries stop working before she reaches the age of 40.
  • Thyroid problems
    An underactive or overactive thyroid gland can prevent the occurrence of ovulation.
  • Chronic long term illness
    Some women who suffer from long term chronic illnesses such as diabetes, cancer or kidney failure may not ovulate.
  • Cushings syndrome
    A hormonal disease that can stop the ovaries from releasing an egg.

Other possible causes of infertility in women include those listed below:

  • Problems with the womb or fallopian tubes
    The fallopian tubes are essentially the pathway from the ovary to the womb, along which the egg travels whilst being fertilised along the way. When the egg reaches the end of its journey down the fallopian tubes, it is then implanted into the lining of the womb where it then grows and matures into a baby.

    However, if either the fallopian tubes or the womb are damaged, or indeed if they stop working, it may then become very difficult to conceive.

    Damage to the fallopian tubes or the womb can be caused by a number of factors. For example, pelvic surgery can sometimes scar the fallopian tubes, whilst cervical surgery can result in a shortening a the cervix (neck of the womb).
  • Pelvic inflammatory disease (PID)
    This is an infection which occurs in areas including the fallopian tubes, womb and ovaries and is usually caused by a sexually transmitted infection (STI). The disease can damage and scar the fallopian tubes, thus meaning the egg is unable to travel into the womb.

  • Endometriosis
    Endometriosis is a condition in which minute pieces of the womb lining begin to grow in other places, such as in the ovaries for example.

    The growth of this sticky tissue or cysts can lead to blockages and mishaping of the pelvis and can also distort the way in which the follicle releases the egg.

Male infertility

For men, the most common cause of infertility is abnormal semen, accounting for 75% of all male infertility cases.

There are a number of explanations for abnormal male semen, some of which can be found listed below:

  • Low sperm count
    Some men have a very low number of sperm, or in some cases they have none at all.
  • Low sperm mobility
    This is where the sperm has difficulty making its way to the egg.
  • Abnormal sperm
    In some cases, sperm may be an abnormal shape which makes it difficult for them to swim to the egg and fertilise it.

Other causes of male infertility include:

  • Testicles
    The primary role of the testicles is to produce and store sperm, meaning that if they are damaged this can heavily impact the quality of semen. Damage can occur through infection, congenital defect, testicular cancer, injury, surgery, a lump in the testicles.
  • Ejaculation disorders
    When a man ejaculates or ‘comes’ during sex, the sperm then travels up the cervix to gain access to the main part of the uterus and into the fallopian tubes. However, problems with ejaculation often means that the sperm is unable to do this.
    • Retrograde ejaculation is where the semen is ejaculated into the bladder, preventing it from taking the path it needs to in order to fertilise the egg.
    • Premature ejaculation is when ejaculation happens too fast. This is a relatively common condition which in many cases may not be so premature as to prevent conception. However, in cases where a man ejaculates before enough semen is deposited into the vagina, the migration of sperm to the fallopian tubes may be difficult.

    Factors affecting both sexes

    Age

    Unfortunately age works against us if we are looking to conceive, and as we age our fertility begins to reduce.

    According to statistics, the biggest drop in fertility levels occurs during our mid thirties. For women who are aged 35, 95% will fall pregnant within three years of having regular unprotected sex. For women who are 38 however, this figure falls to 75%. Whilst fewer statistics exist with regards to male age and fertility, it is thought that men over the age of 35 are half as likely to achieve conception in comparison to men younger than 25.

    Stress

    Stress is a multi faceted aspect of conception. There is a growing body of evidence suggesting that stress does in fact have a direct impact upon fertility - limiting the production of sperm in men, whilst also affecting ovulation within females.

    In addition, many experts are also warning couples attempting to conceive about the indirect impact of stress. Work stress for example, may have an effect upon partner relations, which can in turn lead to a reduction in libido which then leads to a reduced frequency of intercourse.

    In addition, for couples who are desperately willing themselves to conceive, there is certainly a temptation to become an expert in the menstrual cycle, working out exactly when ovulation is occurring, keeping pregnancy tests stock piled in the bathroom and having sex like it is a military operation. To either one partner, or both, making love may begin to simply feel like a routine, and subsequently resentment and stress may set in.

    Weight

    Being outside of a healthy weight range can seriously impact fertility. Women who are overweight or severely underweight for example, will often find that their ovulation is effected, or in some cases it may stop entirely.

    Diagnosing infertility

    Fertility testing and investigation can be a long and drawn out process from start to finish, so if you have reason to be concerned about conception then it is advisable for you to book an appointment with your GP as soon as possible.

     Your GP will be able to give you advice about the next steps and will also carry out an assessment to explore possible areas of concern.

    This will usually include your full medical, sexual and social history to help to identify what may be causing fertility problems. Your age, weight, length of time trying to conceive, and your sex life will usually be the starting points. 

    If it is a sexual problem this is usually easily dealt with. You will also typically be asked about medical conditions, sexually transmitted infections and menstrual cycle.

    Some medications can affect your fertility, so your doctor may prescribe alternative treatments. Your GP will also ask you about smoking, being overweight or underweight, how much alcohol you drink and whether you take recreational drugs or have excessive stress in your life.

    Infertility testing – the next steps

    The Doctor may also conduct a physical examination or refer you for further tests.

    After your GP has considered your medical history and possibly carried out a physical examination, you may be referred to a specialist infertility team at an NHS hospital or fertility clinic for some further tests and procedures.

    For women, there are a number of tests that can be used to try to establish the cause of infertility including tests for Progesterone, Hormones, Thyroid and Chlamydia.

    Other tests, including X-ray or ultra sound scan can detect any blockage of the fallopian tubes or problems around the cervix.

    For men, a semen analysis and chlamydia test can be organised.

    Should I tell my partner I am going to the doctor?

    Yes, absolutely. If you have concerns about your fertility, talk to your partner – after all this is something which affects you both.

    The thought that you may not be able to conceive may make it tempting to sneak off to visit your healthcare provider without another soul knowing, and whilst this is an understandable reaction it is always best to be open and honest about your concerns.

    Tell your other half that you are worried and remember that fertility problems occur equally in men and women so both of you need to be there.

    The realisation that there could in fact be an issue with conception can be an extremely emotional time, and certainly one in which both parties will need as much support from one another as possible.

    When is the right time to seek help?

    For most couples ‘How long will it take to fall pregnant’ is one of the first questions they ask when they begin to actively start trying for a baby.

    Unfortunately there is no set answer to that question, nor is there a definite line after which infertility is declared. Some couples are extremely lucky and find that they conceive after trying for just a short period of time. Others however will find that the process takes far longer, often so long that anxiety, frustration and fear that it may never happen all begin to set in.

    Having concerns about falling pregnant is entirely natural, but at what point should these concerns be taken to a medical professional?

    A couple should visit their GP if they have not conceived after one year of trying, although women over the age of 35, and anyone who is aware that they may have fertility problems (for example those seeking treatment for cancer) should seek help sooner. The GP can check for common causes of fertility problems and will also be able to suggest treatments and lifestyle changes that could help.

    There are two types of infertility:

    • Primary infertility, where someone who has never conceived a child.
    • Secondary infertility, where a person has had one or more babies in the past, but is having difficulty conceiving again.

    Fertility problems are equally divided among men and women with only 5% of cases having no identifiable cause.

    Infertility treatments

    There are three main types of fertility treatment available, and the treatment you are offered will really depend on what is believed to be causing the problem and also what is available from your Primary Care Trust (PCT):

    1. treatment to assist fertility
    2. surgical procedures
    3. assisted conception, which may be intrauterine insemination (IUI) or in-vitro fertilisation (IVF).

    Eligibility

    Whilst the NHS do fund fertility treatment, eligibility and services tend to vary greatly throughout the UK as it is the responsibility of your local PCT to determine factors such as services and availability.

    As a patient it is your right to be referred to an NHS clinic for initial investigation, but be aware that waiting lists in some areas can be extremely long and thus the process may be very drawn out.

    You may wish to consider having private treatment although this can be  expensive and there is no guarantee that it will be successful. It is, however,  important to choose a private clinic carefully. You can ask your GP for advice, and you should make sure that you choose a clinic that is licensed by the Human Fertilisation and Embryology Authority (HFEA).

    Infertility treatments can cause complications including:

    1. side effects of medication
    2. increased risk of ectopic pregnancy
    3. multiple pregnancy
    4. stress.

    All assisted conception clinics in the UK are obligated to offer patients the option of infertility counselling during any stage of their treatment. If you are undergoing treatment or are about to embark upon treatment and you would like to see a counsellor, let your clinic know as soon as possible as there may be a waiting list.

    How could infertility counselling help?

    Research has shown that infertility often has a stressful impact on relationships and can affect a couple’s sex life. The condition is isolating and can impact on how a couple communicate with each other and with the people around them. There can be a profound sense of loss and grief which can impact on closeness. 

    Infertility can also carry with it a sense of denial with sadness and shock borne individually when pregnancy does not materialise. There can also be feelings of fear, guilt and abandonment from the partner who feels the problem lies with them. Women can feel less feminine and men can feel less masculine in the face of infertility. 

    Infertility can also put stress on your relationship, with studies showing that couples dealing with infertility are more likely to feel unhappy with themselves and their marriages. It is important to express the feelings of sadness, loss and anger and to have good support from people around you who understand your position. 

    As mentioned previously, many clinics offering Infertility Treatments also offer counselling or insist that a couple undertake professional counselling before embarking upon investigations and treatment. This can open up channels of communication and keep a couple in contact with each other as they undergo what can turn out to be challenging course of action.


    What should I be looking for in a counsellor or psychotherapist?

    There are no official rules or regulations stipulating what level of training a counsellor dealing with infertility needs. There are however several accredited courses, qualifications and workshops available to counsellors to improve their knowledge of a particular area. With this in mind, you may wish to check to see if a professional has had further training in this area - this could include couples counselling. 

    Another way to assure they have undergone this type of specialist training is to check if they belong to a relevant professional organisation representing counsellors dealing with infertility.

    Further help

    There are many sources of help and information on the Internet. It is useful, however, to check if the help is from a commercial organisation, a charity or governmental agency so that you know if it is impartial and unbiased.

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