A quick review of how pregnancy occurs
Female reproductive organs
To conceive, an egg (ovum) from the woman has to combine with a sperm from the man. An ovum is released from an ovary when a woman ovulates. This usually occurs once a month between 12 and 16 days from the start of her last period if she has a regular monthly cycle of 28-30 days. The ovum travels down a Fallopian tube to the middle of the womb (uterus) over 12-24 hours.
Sperm lie next to the neck of the womb (cervix) when a man comes (ejaculates) during sex. The sperm travel up past the cervix to get into the main part of the uterus and into the Fallopian tubes. If there are sperm in the Fallopian tubes then one may combine with (fertilise) the ovum to make an embryo. The tiny embryo travels down into the uterus and attaches to the lining of the uterus. The embryo then grows and matures into a baby.
What can cause fertility problems?
Ovulation problems in women
Not producing eggs (ovulating) is the cause of problems in about 1 in 4 couples. In some women this is a permanent problem. In some it only happens from time to time: some months ovulation occurs and some months it doesn't. There are various causes of ovulation problems including:
- Menopause:After menopause, women stop having periods and stop ovulating. In some women this occurs earlier than normal. If menopause occurs before the age of 40, it is called premature ovarian insufficiency.
- Polycystic ovary syndrome (PCOS):This can also cause excessive hair growth, acne and period (menstrual) problems, and is associated with being overweight (obesity).
- Hormone problems - for example, too much prolactin hormone. This hormone is produced by the pituitary gland that lies just beneath the brain and is involved with milk production. Too little or too much thyroxine hormone (produced by the thyroid gland in the neck) also affects fertility.
- Being very underweight or overweight. This can affect your hormone balance which can affect ovulation. In particular, women with anorexia nervosa often do not ovulate.
- Excessive exercise (such as regular long-distance running) can affect your hormone balance which can affect ovulation.
- Long-term (chronic) illnesses. Some women with severe chronic illnesses, such as uncontrolled diabetes, cancers and chronic kidney disease, may not ovulate.
- A side-effect from some medicines. Medicines that sometimes cause this include chemotherapy medicines. Some street drugs such as cannabis and cocaine can also affect your ability to ovulate.
- Various other problems with the ovary such as certain genetic problems. (Genetic conditions are those that you are born with and which are passed on through families through special codes inside cells called genes.)
Fallopian tube, cervix or uterine problems
These are the cause in about 2 or 3 in 10 couples with infertility. Problems include:
- Endometriosis, which causes about 1 in 20 cases of infertility. Tissue that normally lines the womb (uterus) - called the endometrium - is found outside the uterus. It is trapped in the pelvic area and can affect the ovaries, uterus and nearby structures. It often causes lower tummy (abdominal) pain and/or painful periods. It can cause a scarring which can block the Fallopian tubes, preventing the eggs reaching the sperm.
- Previous infection of the uterus and Fallopian tubes (pelvic inflammatory disease (PID)) is another common cause. Infection with chlamydia can be a cause of PID. PID can cause scarring and damage which can affect fertility. For example, scar tissue may block the egg (ovum) from travelling down the Fallopian tubes.
- Previous surgery to the Fallopian tubes, the neck of the womb (cervix) or the uterus.
Large fibroids, which may also cause problems, although this is debated by some experts. A fibroid is a non-cancerous (benign) growth of the uterus.
Male problems
In some couples, a condition which might affect fertility is found in the male partner (in 4 out of 10 couples who are having problems with fertility, a problem is found in both partners). Some men are born with testicles (testes) that do not make any sperm or they make very few sperm. Some are born without testicles or without a vas deferens. The most common reason for male infertility is a problem with sperm, due to an unknown cause. The sperm may be reduced in number, less able to swim forwards (less mobile) and/or be abnormal in their form.
There are various factors that may affect sperm production and male infertility. These include:
- Current or past infection of the testicles (for example, mumps).
- Current or past infections of another part of the sperm-producing system, such as gonorrhoea or other sexually transmitted infections.
- Tumours of the testicles.
- Testicles that haven't dropped (descended) properly. Usually this is picked up at newborn baby checks. Baby boys with testicles which haven't descended fully into the scrotum usually have an operation to bring the testicles into place. It is not known for sure if this improves fertility when they are adults but it is thought to do so.
- Side-effects of some medicines and street drugs. These include sulfasalazine, nitrofurantoin, tetracyclines, cimetidine, colchicine, allopurinol, some chemotherapy drugs, cannabis, cocaine and anabolic steroids. Smoking is known to affect the quality of sperm, as is drinking excessive amounts of alcohol.
- Although there is an association between an increased scrotal temperature and reduced semen quality, it is still uncertain whether wearing loose-fitting underwear actually improves fertility.
- Scarring from previous operations (such as an inguinal hernia repair) may block the ducts which carry sperm, and affect fertility.
- A varicocele may possibly affect male fertility. A varicocele is common and is like a varicose vein in the scrotum (the skin that covers the testicles). Varicoceles are found in just over 1 in 10 men with normal sperm and 1 in 4 men with abnormal sperm.
- Certain hormone problems (for example, problems with the pituitary gland in the brain leading to conditions such as Cushing's disease or hyperprolactinaemia).
- Some inherited conditions, due to abnormal genes, may affect the development and function of the testicles. These are uncommon. Examples are conditions known as Klinefelter's syndrome, Kallman's syndrome and testicular feminisation syndrome.
- Being overweight may reduce fertility in men (as well as in women).
Unknown
No cause can be found in about 1 in 4 couples with infertility.
Age can be a factor
Older women tend to be less fertile than younger women. The fall off of fertility seems to be greatest once you are past your middle 30s. 92 out of 100 women aged 19-26 trying to conceive will do so within a year. Between the ages of 35 and 39, this drops to 82 out of 100.
Stress can be a factor
If the male or the female partner is stressed, this can affect libido and how often the couple has sex.
Looking into the problem
Most GPs are happy to talk through any difficulties that you may have concerning fertility. It is best for both partners to see the GP together. It is quite usual for GPs to do the following:
- Ask how long you have been trying to get pregnant and if you have been pregnant before. (This includes asking the male partner if any previous partner of his has been pregnant before.)
- Go over your general health and discuss any past illnesses and infections.
- Ask about any medication or recreational drugs that you may be taking.
- Ask if you smoke and how much alcohol you drink. Your GP may also discuss your weight.
- Ask about your occupation.
- Ask if either partner is feeling stressed at present.
- Talk about sex and be sure there are no sexual problems. Sometimes people ask their doctor about difficulties with fertility when the real problem is difficulty with sex.
- Examine both partners. This can include weighing both partners, a pelvic examination for a woman and an examination of the penis and scrotum for a man.
Do we need any tests?
Your GP may suggest a few tests. For example:
- A sperm test (semen analysis) of the male partner.
- A blood test to check that ovulation occurs in the female partner. This measures the hormone progesterone which is high just after ovulation. The blood sample is taken on the 21st day of a regular 28-day cycle (counting day one as the first day of bleeding).
- They may also suggest some other tests, depending on any other symptoms that you may have. For example, whether the female partner has regular periods or not, etc. Further blood tests or an ultrasound scan may be helpful.
Tests or referral to a doctor who is a specialist are generally not suggested until you have been trying to conceive for 12 months:
- If the female partner is under the age of 36.
- If both partners are otherwise healthy.
- If your GP has not found any problems in the examination or tests that he or she has carried out.
If any of these conditions do not apply, you may be referred earlier to a doctor who is a specialist.
Some general advice
The chance of conceiving gradually goes down over time. However, for couples where no cause is found for the problem, there is still a good chance of conceiving without treatment. In such couples, without treatment, about half who do not conceive within one year conceive within the following year. Therefore, the usual pre-conception advice still applies. For example, women are advised to:
- Take folic acid each day to reduce the chance of a spinal cord problem in a baby.
- Have a blood test to check that they are immune to German measles (rubella). They will be offered immunisation to rubella if they are not immune.
- Eat a healthy diet.
In addition, the following may be relevant to some people:
- Smoking: this can affect fertility in men and women. It has been estimated that in each menstrual cycle, smokers have about two thirds the chance of conceiving compared to non-smokers. Smoking is also harmful to a developing baby if the mother smokes. Therefore, it is a good time for both partners to stop if they are smokers.
- Alcohol in excess: this may affect fertility - both for men and for women. The Department of Health recommends that women trying to become pregnant do not drink any alcohol. However, the exact amount of alcohol that is safe during pregnancy is not known. This is why the advice is not to drink at all. If you do choose to drink when trying to become pregnant then limit it to one or two units, once or twice a week. (This is the equivalent of one or two glasses of wine, once or twice a week.) You should never binge drink or get drunk. This is because alcohol may harm a developing baby.
- Medication: if you take any medication regularly and are thinking about becoming pregnant, discuss this with your doctor in advance. Some medicines can affect a developing baby and may need to be changed before you become pregnant. An important example of this is medicines for epilepsy.
- Diabetes: if you have a medical condition which needs regular monitoring, in particular diabetes, it is very important to start planning before you ever become pregnant.
- Weight control: you have a reduced chance of conceiving if you are very overweight or underweight. For the best chance of conceiving, you should aim to have your body mass index (BMI) at between 20 and 30. If appropriate, see your practice nurse to measure your BMI and for advice about diet and weight control. Participating in a group programme involving exercise and dietary advice has been shown to lead to more pregnancies than weight loss advice alone.
- Some recreational drugs: these can affect fertility and should be avoided.
Sex and fertility
It is best not to try to time when you have sex to coincide with expected ovulation. This may cause anxiety, which can sometimes lead to sexual or relationship problems.
After a couple has had sex, sperm survive for up to seven days. Therefore, even though an egg (ovum) only survives for 12-24 hours, having sex two or three times a week is sufficient if you are trying to conceive. Studies have shown that having sex every two to three days is likely to maximise your chance of getting pregnant. You may want to have sex more often, which is fine, but it probably will not increase your chance of conceiving. It is thought that the more relaxed and spontaneous your sex life, the more likely that you will conceive.
The idea behind using temperature charts and ovulation kits to help predict when you are most fertile is that this can help you time when to have sex. However, using methods like this has not been shown in studies to improve your chance of conceiving. It can also cause a lot of stress within a relationship. They are therefore not usually recommended.
Doctors are used to talking about sexual problems. Any worries or concerns in this area are best talked over with your doctor.
