Difficulties getting pregnant are due to problems with the woman’s fertility - female infertility - about 40 per cent of the time. About 20 per cent of cases are due to male infertility, and some couples have a combination of male and female problems contributing to difficulties conceiving. Sometimes there is no cause found.
Infertility is a common problem, affecting about one in 6 couples in Australia. Infertility is defined by doctors as not having conceived after 12 months of having regular unprotected sex.
There are treatments available to help address many causes of female infertility, and there is also assisted reproductive technology, such as IVF, that can help some women get pregnant.
The only symptom may be difficulty getting pregnant. However, some women may have other signs of fertility problems, such as an irregular menstrual cycle or not having periods at all. There may also be symptoms of conditions that can affect female fertility, such as polycystic ovary syndrome or endometriosis.
Causes of fertility problems in women
There are numerous factors that can affect fertility in women, however the most common causes of difficulties conceiving include the following.
- Problems with ovulation. Ovulation is the release of an egg from one of the ovaries each month. Disruption of ovarian function, leading to irregular ovulation or anovulation (when you don’t ovulate during your menstrual cycle), is the most common reason for fertility problems in women. There are several causes, including polycystic ovary syndrome (PCOS), premature ovarian failure and problems with the pituitary gland.
- Tubal disease. Blockage or scarring of the fallopian tubes may prevent eggs from travelling from the ovary towards the uterus to meet with sperm. Blockages may be due to untreated sexually transmitted infections, such as chlamydia or gonorrhoea, or scarring from previous pelvic or abdominal surgery.
- Endometriosis. This is a condition where the tissue that forms the lining of the uterus is also found outside the uterus, causing inflammation and scarring of the ovaries and fallopian tubes. Scarring can lead to blockage of the fallopian tubes, and some chemicals involved in inflammation may prevent fertilisation of eggs and implantation of embryos.
- Increasing age. As women get older, their eggs reduce in quality and quantity. This decline in fertility accelerates after about age 37, and from age 40 getting pregnant becomes much more difficult.
- Abnormalities of the uterus, such as fibroids (benign growths in the muscle layer of the uterus), can also make it difficult to get pregnant.
Risk factors for female infertility
Additional factors that can influence a woman’s fertility include:
- drinking alcohol, which can affect the quality of your eggs;
- taking illicit drugs, including marijuana;
- taking certain medicines;
- having had treatment for cancer, such as chemotherapy and radiotherapy;
- being very overweight or underweight;
- doing regular, intense, strenuous exercise that results in your periods stopping; or
- having certain other conditions, such as diabetes, thyroid disease or an autoimmune disease (e.g. systemic lupus erythematosus or inflammatory bowel disease).
Having trouble conceiving: when to see the doctor
Doctors recommend most couples see their doctor if they are having difficulty conceiving after 12 months of trying to get pregnant. If the woman is older than 35, it’s usually recommended that you see your doctor after 6 months of trying. You should also see your doctor sooner if you or your partner have any known conditions or risk factors that may affect your fertility.
Investigation of infertility
Your doctor will ask about how long you have been trying to conceive and also when during your cycle and how often you have sex. They will also ask about your menstrual cycle and whether you have ever been pregnant.
Your doctor will take a medical history, looking for any possible causes of fertility problems and perform a physical examination. Your doctor may then recommend tests to work out the cause of your fertility problems, or they may refer you to a fertility specialist for further evaluation and treatment.
Fertility blood tests
Ovulation test: The most common simple test for ovulation is a measurement of the progesterone level in the blood during the second half of the menstrual cycle. This test can determine whether you are ovulating or not.
Further blood tests, such as levels of other hormones (including oestrogen, follicle stimulating hormone, luteinising hormone, thyroid stimulating hormone or prolactin) may be done to look for causes of ovulation disorders.
Ovarian reserve test: A blood test measuring anti-mullerian hormone (AMH) may be recommended to give an indication of your ovarian reserve - the number of eggs still in your ovaries, and whether it is normal for your age.
Genetic tests may be recommended in some cases of infertility.
Imaging tests may include:
- An ultrasound of the female reproductive organs. This is an ultrasound showing the uterus, fallopian tubes and ovaries. It is usually performed transvaginally (with the transducer gently placed in the vagina) to get detailed images. This test is often done first as a guide to further testing, and can detect problems such polycystic ovaries or fibroids in the uterus.
- A special X-ray scan of the uterus and fallopian tubes called a hysterosalpingogram. This involves an injection of dye into the uterus to outline any structural problems or blockages in the fallopian tubes. In some cases this procedure may help unblock fallopian tubes.
- Hysterosalpingo-contrast sonography (HyCoSy) - also called a sonohysterogram. This is similar to a hysterosalpingogram, but uses ultrasound images rather than X-rays.
Laparoscopy involves using an instrument to look inside the pelvis through a tiny cut in the abdomen, carried out under a general anaesthetic.
Laparoscopy can be used to assess the fallopian tubes and look for endometriosis in the pelvis. It has the advantage that if endometriosis is found it can be treated at the same time.
Options for the treatment of fertility problems in women will depend on the cause of the problem, as well as your age and personal preferences and include:
- Lifestyle changes, such as reducing your alcohol intake, quitting smoking or ensuring you have a healthy body weight, to help improve fertility.
- Medicines to stimulate ovulation (including clomiphene), which are recommended for some women with irregular ovulation or anovulation.
- Surgical treatment if there are problems with the uterus, such as fibroids or endometriosis. Surgery is often done via laparoscopy or hysteroscopy (where a narrow tube with a camera on the end is passed through the cervix to look at the inside of the uterus).
- Assisted reproductive technology (see below).
Women with conditions such as endometriosis or polycystic ovary syndrome should be treated for these conditions to help improve fertility.
Assisted reproductive technology (ART)
Assisted reproductive technology can be used to help some couples conceive. ART includes any procedure where eggs, sperm or embryos are handled outside the body. These infertility treatments often take considerable time and there is usually a significant cost involved. Some of the costs may be covered by private health insurance. Medicines involved in IVF are no longer fully subsidised by Government and you will have to pay part of the cost if any medicines are required.
Intrauterine insemination (also called IUI)
Intrauterine insemination (sometimes called artificial insemination) involves inserting specially prepared sperm into the uterus, with or without taking medicine beforehand to stimulate ovulation. This treatment is often used to help women get pregnant when there is unexplained or male-related infertility.
In-vitro fertilisation (IVF)
IVF is the most commonly used and most effective treatment for infertility. It is usually the first treatment recommended for women with blocked fallopian tubes.
IVF is generally performed at a specialist clinic. The treatment cycle involves taking hormonal medicine for several weeks to stimulate your ovaries to produce multiple eggs, which are then retrieved from your ovaries using a needle (under local or general anaesthetic). The eggs are put into a special dish in a laboratory and sperm is added to the dish to fertilise the eggs. Fertilised eggs that develop into embryos can then be inserted into your uterus after about 3-5 days. Blood tests are taken after several days to determine whether the embryo has implanted in your uterus, forming a pregnancy.
If multiple eggs are fertilised, some of the embryos may be frozen so that they can be used later, if needed.
IVF success rates vary, depending on factors such as your age, the cause of infertility and where you have your treatment. In Australia there is no agreed format for reporting success, so the data may be presented in different ways. You should check with your clinic how their success rates are reported so that you understand exactly what their figures mean.
It’s possible to use donor eggs, sperm and donor embryos if there are problems conceiving because of problems with the eggs or sperm (or both). Older women experiencing fertility problems may want to consider the use of donor eggs from a younger woman to increase the likelihood of becoming pregnant.
It’s important to discuss the risks and benefits of IVF with your doctor, as there are side effects associated with IVF and treatment can be emotionally taxing and expensive.
Intracytoplasmic sperm injection (ICSI)
This is a form of ART often used to treat male infertility. Eggs are collected in the same way as for IVF procedures, but then a single, healthy sperm is injected directly into an egg. In some cases, sperm can be surgically retrieved from the testicles to be used for ICSI.
Women with a problem with their uterus or a medical condition that means being pregnant is a risk to their health may consider using a surrogate (gestational carrier) to help them have a baby. It involves using IVF to create an embryo with your egg and your partner’s sperm (or donor egg and sperm) which is then transferred into the uterus of a gestational carrier.
This is a complex situation and in Australia there are conditions that must be met regarding such an arrangement, including counselling for everyone involved. Your doctor can advise you on this process.
Support for couples facing infertility
Having difficulty getting pregnant and being diagnosed with fertility issues can be a very stressful time for many couples, and can place strain on you as a couple.
Talk to your doctor about how you are feeling - support is available. Support groups and counsellors can help you deal with the emotional toll that fertility issues can create. Talking to other couples who face similar challenges is often very helpful.
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