Understanding Infertility

If you’re having trouble conceiving, it’s natural to wonder which factors may be causing your fertility difficulties. Find out which factors influence your fertility and whether you should consider seeking medical help. 

Is it my fault?
 

It is common to find it difficult to get pregnant, with an estimated 9 % of the global population struggling to conceive.²

Many factors could be causing your infertility, and you shouldn’t focus on whose ‘fault’ it is.  

• Around 1/3 of infertility cases are caused by fertility problems in women.¹
• 1/3 of infertility cases are caused by fertility problems in men.¹       
• 1/3 of infertility cases are caused by a mixture of males and female problems, or by problems that cannot be determined.¹  

Infertility isn’t necessarily a permanent condition and it doesn’t mean that you’ll never have a child. You may just need a little specialist help to get there.

What are the causes of female infertility?

Once you and your partner have undergone fertility tests, your doctor will diagnose the cause your fertility problems.

Unfortunately, sometimes there is no clear factor and you may be diagnosed with unexplained infertility. In this case, your doctor may recommend undergoing more advanced fertility treatment such as Assisted Reproductive Technology (ART).²

Female age³

• As you get older, your fertility begins to decline.
• A healthy 30-year-old woman has around a 20 % chance of conceiving each month.³
• However, a 40-year-old woman has less than a 5 % chance of conceiving each month.³
• As you get older, it becomes more likely that you’ll need to undergo ART treatment in order to conceive.

Ovulation Problems⁴

• These account for around 25 % of fertility difficulties.
• Each month, your ovaries must release a healthy egg (ovulation) to conceive. If you have irregular or absent periods, are overweight or underweight, you may not be ovulating.
• Ovulation problems can usually be treated with medication.

 Blocked fallopian tubes

• Tubal disease accounts for between 25 % and 35 % of female infertility⁶ .
• Your fallopian tubes are very delicate, and can easily become blocked or damaged.
• Blockages can be caused by scarring from a previous infection or abdominal surgery.⁵ 
• This blockage can prevent sperm from reaching your egg, and interfere with an embryo’s development and its subsequent implantation into your uterus lining.⁵ 
• Blocked fallopian tubes may be treated with surgery, or you may need to undergo in vitro fertilisation (IVF). ⁵

Endometriosis⁷ 

• Between 30 % and 50 % of infertile women have endometriosis.
• Endometriosis occurs when tissue that usually lines the inside of your uterus grows on your ovaries, fallopian tubes, or on the outside surface of your uterus. This can cause heavy and painful periods, scarring, and adhesions (organs sticking together).
• A small keyhole surgery (laparoscopy) will determine whether you have endometriosis.
• It can usually be treated by medication and surgery, and you may have to undergo an ART treatment.

 

Fibroids⁸

• Around 5–10 % of fertility problems are caused by fibroids (myomas or leiomyomas), however most women with fibroids will not be infertile.
• These are non-cancerous growths made up of muscle and tissue that develop in or around your uterus.
• They can change the shape and size of your uterus or cervix, making it difficult for sperm to reach your egg or an embryo to implant into the lining of your uterus.
• The exact cause of fibroids is unknown, and whether they cause symptoms depends on their location, size and number.
• Doctors will manage fibroids based on the woman’s unique situation. You should discuss with your doctor if you had a fibroid removed.

Polycystic ovary syndrome (PCOS)

• Between 70% and 80% of women with PCOS may be infertile.⁹
• PCOS causes your ovaries to become enlarged with many small cysts, which can be seen using an ultrasound scan.⁴
• This can cause irregular periods which can affect ovulation, and thus impact your fertility⁴ 
• It can be treated with medication or surgery, and you may have to undergo an ART treatment.⁹

Cervical problems

• Between 3 % and 8 % of female infertility cases can be attributed to abnormalities of the cervix.¹⁰
• Cervical mucus helps sperm to move through your vagina to reach your egg.¹¹ 
• Some women may not have enough mucus, it may be too thick and sticky or contain antibodies that are hostile to sperm.¹¹
• Problems with cervical mucus may be treated with medication, by placing sperm directly into your uterus, or with an ART treatment that brings together your egg and sperm outside of your body.¹¹

Pelvic inflammatory disease (PID)

• Sexually transmitted infections (STIs) such as chlamydia or gonorrhoea can cause pelvic inflammatory disease (PID).¹²
• PID can cause blockages in your fallopian tubes and increase the risk of having an ectopic pregnancy.¹²
• An ectopic pregnancy occurs when an embryo implants outside of the uterus.¹²
• Blockages in your fallopian tubes can potentially be treated with surgery, or you may need to undergo an ART treatment.⁵

Early menopause³

• Menopause is a natural process that women go through in which their periods stop and they are no longer fertile.
• Some women undergo an early menopause and their periods stop before they are 40 years old.
• If you have undergone an early menopause, you’ll need to undergo ART treatment in order to conceive and/or use donor eggs (note that availability may vary between countries as egg donation is not offered in all regions).

 

Seeking help

The thought of you possibly being infertile can be hugely distressing. Feeling overwhelmed about your future is completely normal and you may need extra support from those close to you. 

You should speak to a doctor about your fertility if:

• You know that you have or had any of the conditions listed above.
• You are under 35 years old and have been trying to conceive for 1 year.³ 
• You are over 35 years old and have been trying for 6 months.³

References

1. US Department of Health & Human Services. Available at: https://opa.hhs.gov/reproductive-health/understanding-fertility-basics.      Accessed October 2022.

2. Boivin J, et al. New Debate: International estimates of infertility prevalence and treatment-seeking: potential need and demand          for infertility medical care. Hum Reprod 2007; 22(6):1506–1512.

3. American Society for Reproductive Medicine (ASRM). Age and fertility. A guide for patients. 2012. Available at:                                  http://www.reproductivefacts.org/globalassets/rf/news-and-publications/bookletsfact-sheets/english-fact-sheets-and-info-                booklets/Age_and_Fertility.pdf. Accessed October 2022. 

4. American Society for Reproductive Medicine (ASRM). Medications for inducing ovulation. A guide for patients. 2016. Available at:      http://www.reproductivefacts.org/globalassets/rf/news-and-publications/bookletsfact-sheets/english-fact-sheets-and-info-                booklets/booklet_medications_for_inducing_ovulation.pdf. 2014. Accessed October 2022.

5. Khalaf Y. Tubal subfertility. BMJ. 2003; 327:610–613.

6. American Society for Reproductive Medicine (ASRM). Role of tubal surgery in the era of assisted reproductive technology: a              committee opinion. Fertil Steril 2015; 103:e37-e43.

7. American Society for Reproductive Medicine (ASRM). Endometriosis: does it cause infertility? Fact Sheet. 2016. Available at:              https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-            booklets/endometriosis-does-it-cause-infertility/. Accessed October 2022.

8. American Society for Reproductive Medicine (ASRM). Fibroids and fertility. Fact sheet. 2015. Available at:                                          http://www.reproductivefacts.org/globalassets/rf/news-and-publications/bookletsfact-sheets/english-fact-sheets-and-info-                booklets/fibroids_and_fertility_factsheet.pdf. Accessed October 2022.

9. Melo AS, et al. Treatment of infertility in women with polycystic ovary syndrome: Approach to clinical practice. Clinics. 2015;            70(11):765–9.

10. Martyn F, et al. The role of the cervix in fertility: Is it time for a reappraisal? Hum Reprod. 2014; 29(10):2092–8.

11. Maher MA, et al. Cervical mucus removal prior to intrauterine insemination: a randomized trial. BJOG An Int J Obstet Gynaecol.          2018; 125(7):841–7.

12.NHS. Pelvic inflammatory disease. 2022. Available at: https://www.nhs.uk/conditions/pelvic-inflammatory-disease-pid.                      Accessed October 2022.

13. Farrow A, et al. Prolonged use of oral contraception before a planned pregnancy is associated with a decreased risk of delayed          conception. J Hum Reprod 2002; 17: 2754-2761.

 

ZA-NONF-00157. October 2022

If you’ve been trying to conceive for a while, you may be wondering why your partner isn’t pregnant yet. Learn what factors can influence your fertility and whether to consider seeking medical help. 

What is infertility?

Infertility is medically defined as the inability to conceive after 12 months of unprotected sex.^1,2

However, if your partner is 35 years old or over, you or your partner may be considered infertile if you haven’t conceived after 6 months of unprotected sex.³ 

Sometimes, a couple who’ve already had a child can have trouble conceiving again. This is called secondary infertility.²

Is it my fault? 

 

There are many factors that may be causing your fertility difficulties. 

• Around 1/3 of infertility cases are caused by fertility problems in men.⁴
• 1/3 of infertility cases are caused by fertility problems in women.⁴
• 1/3 of infertility cases are caused by a mixture of male and female problems, or by problems that cannot be determined.⁴

Infertility doesn’t necessarily mean that you won’t ever have children, but you may need the help of fertility treatment to conceive. 

What are the causes of infertility? 

Your doctor will carry out a series of tests to diagnose what’s causing your fertility difficulties. Depending on the cause, your doctor will recommend a treatment path for you. 

Frustratingly, sometimes there may be no clear reason and you may be diagnosed with unexplained infertility. In this case, your doctor may recommend advanced fertility treatment known as Assisted Reproductive Technologies (ART) treatment. 

Optimal sperm conditions

Although only one sperm is needed to fertilise your partner’s egg, the enzymes from multiple sperm are needed to break down the egg’s protective barrier. 

In order to conceive, your sperm must be⁵: 

• Highly concentrated — normally, there should be at least 15 million sperm in every ml of semen.
• Moving well (motile) — motility helps your sperm to swim to your partner’s egg.
• Normally shaped — healthy sperm should have an oval head and a long tail.

You may find that your semen contains a very low number of sperm (oligozoospermia), or no sperm at all (azoospermia).⁶ In this case, your doctor may recommend surgically extracting sperm from part of your reproductive tract to help you to conceive.⁶ 

Sperm production problems 

One of the most common causes of male infertility is problems with sperm production. 

Several sperm production problems can contribute to infertility, including:  

Scrotal varicose veins (varicoceles)⁷

• Scrotal varicose veins (varicoceles) are swollen veins causing your testicles to get hotter and affect the production of sperm.
• These are treated with surgery.

Testicular injury⁸ 

• Serious trauma to the testicles such as becoming twisted (torsion), can affect sperm production.
• The twisting of the testis cuts off the blood supply, damaging the tubes that produce sperm.
• Previous injuries can’t be treated, but an ART treatment may help you to conceive.

Undescended testicles⁸ 

• In the uterus, baby boys’ testicles form in their abdomen and descend into their scrotum shortly before birth.
• Some men’s testicles don’t descend before they are born (cryptorchidism), although in these cases they usually drop in the first six months after birth.

Testicular cancer⁸ 

• Cancer, and in particular testicular cancer, can affect fertility.
• This is treated either by surgery, medication, radiotherapy or chemotherapy. However, cancer therapy can also damage sperm production.

Genetic defects⁸ 

• Sometimes, genetic information on the Y chromosome (which is only present in men) is deleted (micro-deletions), which can reduce the production of sperm.
• Depending on where the micro-deletion is on the chromosome, this may be treated by surgically extracting sperm from part of your reproductive tract.
• However, some couples may need to consider using a donor sperm to conceive.

Mumps⁸ 

• Contracting mumps (or mumps-related orchitis) after puberty may damage the sperm-producing cells in your testicles, causing infertility or subfertility.
• Mumps infections are now less common due to immunisation programs.

Anti-sperm antibodies⁸ 

• In some men, the immune system reacts to the man’s own sperm, making antibodies which attach to the sperm.
• Often these antibodies won’t have an effect, but in some cases they may reduce the number of sperm, or cause the sperm to clump together. Clumping will reduce their ability to swim to reach the egg for fertilisation to occur.
• There are ART treatments available to manage the effects of these antibodies.

Lifestyle ⁸ 

• Sperm production can be affected by a range of lifestyle factors, including smoking, drinking, use of anabolic steroids, or being overweight.
• Environmental factors can also affect your sperm quality, including overheating of your testicles, some sexual lubricants, the chemicals involved in certain manufacturing, painting or printing jobs.
• These factors are treated by making lifestyle changes, such as wearing loose clothing to avoid overheating.

Hormonal problems⁸ 

• Some men have a natural deficiency in follicle-stimulating hormone (FSH) and luteinising hormone (LH), which prevents the testicles from producing testosterone or developing healthy sperm.
• Hormonal problems can usually be treated with medication.

Obstruction problems

Blocked sperm ducts 

• Occasionally, male sperm ducts (epididymis and vas deferens) can become blocked, meaning that your semen doesn’t contain any sperm.⁶
• This can be treated with surgery, or sperm may be surgically extracted from part of your reproductive tract.⁸

Vasectomy⁸ 

• Some men have had a previous vasectomy to stop them being able to conceive. This can sometimes be reversed using surgery.
• The procedure’s success depends on how long ago your vasectomy was performed.

Does age affect male fertility? 

Unlike women, whose fertility significantly declines after the age of 35, men’s fertility doesn’t decline until they are much older. Although sperm quality deteriorates as men age, this does not create a problem until after the age of 60.³ 

Are there any symptoms? 

In most cases, there are no obvious symptoms that you may be infertile. Usually, you’ll still be able to maintain erections and have sex, and the quantity and appearance of your semen will also be normal. 

If you’re worried about your fertility, the best thing to do is talk to your doctor. They’ll recommend some simple fertility tests, more information about which can be found here. 

Can I still father a child? 

Over the past three decades, huge advancements in fertility science have helped millions of couples to overcome their difficulties and have children of their own.⁹ 

However, if your doctor diagnoses you with infertility, then it’s likely that you’ll need some additional help to conceive. 

This may be as simple as timing when you have sex, or you may need more advanced fertility treatment. 

Discovering that you’re infertile can be overwhelming, but the right support can help you to conceive successfully. Understanding what’s causing your fertility difficulties can help you find out what treatment is right for you and your partner.

   

References

1. Boivin J, et al. New Debate: International estimates of infertility prevalence and treatment-seeking: potential need and demand          for infertility medical care. Hum Reprod. 2007; 22(6):1506–1512.

2. Zegers-Hochschild et al. The International Glossary on Infertility and Fertility Care. Hum Reprod. 2007; 32(9):1786–1801.

3. American Society for Reproductive Medicine (ASRM). Age and fertility. A guide for patients. 2012. Available at:                                  https://www.reproductivefacts.org/globalassets/rf/news-and-publications/bookletsfact-sheets/english-fact-sheets-and-info-              booklets/Age_and_Fertility.pdf Accessed October 2022.

4. US Department of Health and Human Services. Understanding Infertility Basics. Available at: https://opa.hhs.gov/reproductive-          health/understanding-fertility-basics. Accessed October 2022.

5. Mayo Clinic. Healthy sperm: Improving your fertility. 2020. Available at https://www.mayoclinic.org/healthy-lifestyle/getting-            pregnant/in-depth/fertility/art-20047584. Accessed October 2022.

6. Jungwirth A, Giwercman A, Tournaye H, Diemer T, Kopa Z, Dohle G, et al. European association of urology guidelines on male            infertility: The 2012 update. Eur Urol. 2012;62(2):324–32.

7. Speroff L. Male infertility. Clin Gynecol Endo Infertil. 1999; 8:452–459.

8. Healthy Male: Andrology Australia. Male infertility. 2020. Available at: https://www.healthymale.org.au/mens-health/male-                infertility#resources. Accessed October 2022.

9. European Society of Human Reproduction and Embryology (ESHRE). ART fact sheet. Available at                                                        https://www.eshre.eu/Europe/Factsheets-and-infographics. Accessed October 2022.

 

ZA-NONF-00158 October 2022

Should I speak to a doctor?

Talking about your sex life and contraception may seem uncomfortable, but if you’re worried about your fertility then it’s best to seek help as soon as possible.

Take the self-assessment questionnaire here to find out whether you should speak to a doctor. 

Which doctor should I speak to?

There are many different doctors that specialise in infertility. As a first port of call, you should visit one of the following: 

• Family doctor – depending on when you started trying to conceive, they will perform basic fertility tests and may refer you to a fertility specialist.
• Gynaecologist – these specialists can perform more advanced fertility tests for women and may make a referral to a fertility clinic.
• Urologist – these specialists can perform more advanced fertility tests for men.
• Fertility specialist – these specialists generally work within a fertility clinic and are able to further assess causes and work with you to plan possible treatments. You do not need a referral to visit a fertility specialist and may choose to visit one directly.

Your first fertility clinic visit  

What happens at your appointment?

During your first appointment, you’ll need to be ready to share intimate details of your personal life, and to undergo a thorough physical examination.

Fertility treatment may last for several months, and sometimes even years. You may need to repeat yourself, or tests, several times throughout your treatment journey.

When starting treatment, there will be a lot of information to take in. Having your partner, friend or family member present can reassure you that you haven’t missed anything important. It will also be easier for your partner to hear information first-hand, rather than you having to relay it later.

Do not be afraid to ask your doctor to explain if there is something which you don’t understand. You can always take notes during consultations, or even record the conversation if everyone present agrees.

What kinds of questions will your specialist ask?

During your first appointment, your doctor will ask you and your partner about:

• Your medical and personal history in detail.
• Your diet and lifestyle.
• Your current sex life and how long you’ve been trying to conceive.

What types of questions should you and your partner ask?

• What tests are available to diagnose infertility for women/men?
• What does each test involve?
• Who will carry out the test?
• Are they painful?
• When will we get the results?

Once you have your test results you should ask:

• Based on our test results, what are our fertility treatment options?
• How does this treatment work?
• What is the success rate for this treatment (in terms of live births) for couples like us?
• What are the side effects associated with this treatment?
• What do we do next if this treatment doesn’t work?
• What’s the success rate of this treatment at your clinic?
• How often will I come into the clinic?
• Does your clinic provide emotional counselling, or can you refer us to a fertility counsellor?
• Where can we find out more information about this treatment?

Preparing a list of questions to ask the fertility specialist in advance can help give more structure to appointments, ensuring you have covered everything you need to know before starting your treatment journey.

ZA-NONF-00159. October 2022.

What are fertility doctors testing for at the clinic?   

Your fertility doctor will check that you and/or your partner have:^1,2   

• The right balance of hormones to help eggs to mature.
• Regular ovulation.
• A healthy, functioning uterus and intact fallopian tubes.
• A healthy, functioning penis and testes, with no physical abnormalities.

Who performs the fertility tests at the clinic?   

Your fertility team is made up of a range of doctors and fertility nurses, along with specialists such as reproductive endocrinologists and embryologists, who oversee more complex treatments such as in vitro fertilisation (IVF).   

Ask your doctor or fertility team in the clinic about their different roles and how they will be supporting you.  

What type of tests are performed for women?   

Preliminary tests   

• Personal history¹

You will be asked about your medical history and sex life in detail. If you feel uncomfortable discussing anything in front of your partner, ask to speak with your doctor in private.

• Physical exam¹

You may have a pelvic examination to check for any infections, or abnormalities which could be linked to fibroids, endometriosis or pelvic inflammatory disease. Your weight and body mass index (BMI) will be measured to assess whether you have a healthy body weight.

• Cervical screening (smear) test²

You may be asked about your most recent cervical screening test or a new test may be performed. This helps to rule out any infection or abnormal cells on your cervix.

• General health tests²

You may be tested for rubella (German measles), chlamydia, hepatitis B and C, and human immunodeficiency virus (HIV).

• Hormone blood and urine tests²

These tests will be taken on specific days of your menstrual cycle to measure different hormone levels. These will help to determine if you are ovulating, as well as the quality and quantity of the eggs produced (your ovarian reserve). This can help predict the ovary’s response to IVF treatments.

More advanced fertility tests 

• Antral follicle count (AFC)²

This test uses an internal ultrasound scan to show the number and size of follicles present in the ovaries.

• Hysterosalpingogram (HSG)³

This test applies a coloured dye inside the uterus to check the shape and size of the uterus and fallopian tubes. It will also show the doctor if there are any tubal blockages.

• Laparoscopy³

This test involves the insertion of a small surgical telescope into the abdomen, under general anaesthetic. This can check for any blockages, growths or signs of endometriosis around the uterus and fallopian tubes.

What types of tests are performed for men? 

Preliminary tests 

• Personal history¹

You will be asked about your medical history and sex life in detail. If you feel uncomfortable discussing anything in front of your partner, ask to speak with your doctor in private.

• Physical exam⁴

Your doctor will usually examine your penis and your testicles to check for any abnormalities. Your doctor will be looking for varicose veins around your scrotum (varicoceles) which can affect fertility. They will also check that your sperm ducts (epididymis and vas deferens) are present and intact.

• Blood and urine tests²

You can be tested for rubella (German measles), hepatitis B and C and human immunodeficiency virus (HIV).

Semen analysis⁴ 

You may be asked to provide a semen sample. This is done by masturbating either at home or at your clinic. The quality and volume of semen will be tested, including sperm count, concentration, movement (motility), size and shape (morphology) of your sperm. 

Testicular biopsy⁴ 

A testicular biopsy may be performed if no sperm have been seen in your semen sample. You will be given an anaesthetic and your doctor will remove a small sample of tissue from one of your testicles. This sample will be tested to see if it contains any sperm that can be used in fertility treatment.

More advanced fertility tests 

• Ultrasound scan (scrotal ultrasound)^5,6

This scan shows any blockages or varicoceles around your testicles or sperm ducts that could be causing your infertility. Your doctor will pass a small device back and forth over your scrotum to pick up soundwaves, which are converted into an image. The trans-scrotal ultrasound is non-invasive and painless.

• Transrectal ultrasound^5,6

This scan shows a more thorough overview of your prostate, the glands which produce your semen (seminal vesicles), and the sperm duct which carries sperm from your testicles to your urethra (vas deferens). Your doctor will insert a thin probe into your rectum while you lie on your side.

Next steps 

It is natural to want answers straight away but unfortunately, fertility testing can take some time. Unfortunately, even after testing, some couples find that the reasons for their fertility difficulties remain unknown and they will be diagnosed with unexplained infertility.

It’s important to try to remain positive during this time. Getting a diagnosis is an important step forward in defining the right treatment to help you conceive.

References

1. National Health Service. Infertility, Diagnosis. 2020. Available at: https://www.nhs.uk/conditions/infertility/diagnosis/#questions-      your-doctor-may-ask. Accessed: October 2022.

2. National Institute for Health and Care Excellence (NICE). Fertility problems: assessment and treatment: CG156. 2017. Available        at: https://www.nice.org.uk/guidance/cg156. Accessed: October 2022.

3. Khalaf Y. Tubal subfertility. BMJ. 2003; 327:610-613.

4. Healthy Male: Andrology Australia. Male infertility. 2020. Available at: https://www.healthymale.org.au/mens-health/male-                infertility#resources. Accessed: October 2022.

5. Kliesch S. Diagnosis of Male Infertility: Diagnostic Work-up of the Infertile Man. Euro Uro Suppl 2014; 13(4):73-83.

6. Ammar et al. Male infertility: the role of imaging in diagnosis and management. The British Journal of Radiology. 2012; S59-S58.

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