Learn about infertility, a common problem faced by couples and individuals, what causes it and how it is treated.

If you are trying to conceive but face difficulties getting pregnant, you may wonder what is going on and if there are steps you can take.

This article discusses infertility, a common problem affecting an estimated one in six couples. Learn more about this condition and speak to a fertility specialist about the next steps.

What is infertility?

Infertility is the inability to conceive after engaging in regular and unprotected sexual activity for a minimum of one year. This term may also encompass women who can conceive but struggle to carry a pregnancy to term.

Infertility may be diagnosed in two forms:

  • Primary infertility is when an individual or couple has never been previously pregnant and has not conceived a baby after having unprotected sex for 12 months.
  • Secondary infertility is when an individual or couple who has had one or more pregnancies in the past is unable to conceive again.

How common is infertility?

Infertility is a prevalent issue worldwide that affects many individuals of reproductive age. The World Health Organization (WHO) estimates that approximately 48 million couples and 186 million individuals live with infertility globally. Although millions worldwide experience infertility, there is a lack of accurate data due to differing definitions and inconsistent demographic research.

Is infertility just a female problem?

Both males and females experience fertility issues. Men are estimated to be responsible for or contribute to around 50% of infertility cases.

What causes male infertility?

Male infertility may occur for various reasons:

  • Abnormal sperm production. Issues with sperm production (also called spermatogenesis) can lead to poor sperm parameters, such as low sperm count. This may occur due to undescended testicles, trauma to the testes, genetic disorders, medical conditions, or infections, such as chlamydia, mumps or HIV.
  • Abnormal sperm function. Poor sperm motility (movement) and morphology (form) can impact a sperm's fertilising potential. Additionally, sperm functioning may be impaired by DNA fragmentation, which is when the genetic material contained in a sperm cell is damaged.
  • Varicocele, which is a pooling of blood in veins in the scrotum.
  • Ejaculatory dysfunction, such as premature or retrograde ejaculation.
  • Structural blockages in the male reproductive tract that can affect the transport of sperm. This may be due to an injury, infection, surgery, or irregular development.
  • Cancer and cancer treatments. Common cancer treatments, such as radiation or chemotherapy, can impair spermatogenesis and damage sperm. Particular cancers, such as testicular cancer, can also impact fertility.
  • Hormonal disorders. When the testicles or related glands do not function properly, this can result in hormone imbalance, which can in turn impair reproductive processes. Hypothalamic or pituitary gland malfunctioning can lead to low or no sperm production due to excessive prolactin production or other disorders that affect the function of these glands. A lack of testosterone production in the testes can result in male hypergonadotropic hypogonadism, which can also impact spermatogenesis and cause erectile dysfunction.
  • Certain genetic disorders, such as cystic fibrosis, Klinefelter's syndrome, Y-chromosome micro-deletion, and myotonic dystrophy, can lead to the absence of sperm or reduced sperm production.
  • Age. Fertility in men tends to decrease with age, and those aged 40 and above are usually less fertile.

What causes female infertility?

For a woman to become pregnant, several conditions must be met, including having vaginal intercourse around the time of ovulation, the proper functioning of the reproductive system, and balanced hormones. Various factors can potentially interfere with this process and cause infertility.

Any of the following may cause female infertility:

Ovulation disorders. Infrequent or absent ovulation accounts for approximately 30% of female infertility. Some ovulation disorders include:

  • Polycystic ovary syndrome (PCOS). While the exact cause is unknown, this condition is characterized by irregular periods, an excess of male hormones (called androgens), and numerous fluid-filled cysts that develop in the ovaries (referred to as polycystic ovaries). PCOS can also result in acne, excess hair growth in a male-pattern (known as hirsutism), and weight gain.
  • Hyperprolactinemia. This is a condition where an excess of the hormone prolactin, which is also responsible for milk production, can prevent ovulation. Having a thyroid hormone deficiency (also known as hypothyroidism) can also affect the menstrual cycle, impacting fertility. Tumours, eating disorders and excessive exercise can also be underlying causes.
  • Primary ovarian insufficiency (POI). POI is a condition where the ovaries do not function properly, and a woman's period becomes highly infrequent or absent before age 40. POI is found to be related to certain immune system diseases, genetic disorders (such as Turner syndrome and Fragile X syndrome) and cancer treatments (such as chemotherapy and radiation).
  • Diminished ovarian reserve (DOR). Ovarian reserve refers to the number of egg cells capable of fertilisation that remain in the ovary. DOR is a condition in which the number of eggs is less than expected for a particular age. This condition can happen due to various causes, such as endometriosis, autoimmune disorders, prior ovarian surgery, tubal disease, chemotherapy, radiation therapy, or genetic disorders, such as Fragile X syndrome. Having DOR does not mean that a woman cannot conceive naturally; still, she may benefit from fertility treatments, like hormone therapy or egg freezing.
  • Functional hypothalamic amenorrhea (FHA). FHA is characterized by a lack of menstruation (known as amenorrhea). It is diagnosed by excluding other causes of amenorrhea, and is associated with factors like excessive exercise, stress, and caloric restriction (such as in extreme dieting or anorexia).

Irregularities in the uterus. Issues with the cervix (the opening of the uterus), uterine polyps, and an irregularly shaped uterus may lead to infertility. Additionally, uterine fibroids, which are benign growths, can block the fallopian tubes or prevent implantation.

Damage to the fallopian tubes or tubal blockage. This may be caused by inflammation due to conditions like pelvic inflammatory disease (PID) or endometriosis. Other common pelvic adhesions (fibrous bands of scar tissue), which can develop due to previous surgery, a past ectopic pregnancy, and fibroids.

Cancer and cancer treatments. Similar to male infertility, both particular cancers and treatments can cause female infertility.

Age. Women's ability to conceive naturally begins to decrease after age 30, decelerating more intensely after age 35.  

What are risk factors for infertility?

There are similar risk factors for infertility in both men and women:

Environmental factors

Studies show that chemicals found in air, water, food, and certain products can harm fertility. Men may experience decreased sperm count, while women may have trouble with ovulation and fetal health. Consult with a fertility specialist on evaluating and decreasing exposure to environmental toxins.
For men, consistently exposing the testicles to high temperatures can increase testicular temperature and impact sperm production. Although more research is needed, studies have associated this with working in an environment with heat exposure or sitting with your legs together for an extended period.

Lifestyle factors

  • Smoking. Cigarette use can decrease the chances of pregnancy for both partners and reduce the effectiveness of fertility treatment. Women who smoke frequently are more likely to experience miscarriages. In contrast, men may experience erectile dysfunction and lower sperm count due to smoking.
  • Alcohol use. When trying to conceive, it is a good idea for both men and women to moderate their consumption of alcohol, as excessive consumption can contribute to infertility.
  • Being overweight. Obesity and being overweight can have an impact on fertility. Men who are overweight may experience a decrease in sperm count and quality, while obesity in women is associated with an increased risk of miscarriage and poor pregnancy outcomes.
  • Being underweight. People who have eating disorders or follow an extremely low-calorie or restrictive diet are at risk of experiencing fertility problems.
  • Excess or lack of exercise. A sedentary lifestyle can lead to obesity, increasing the risk of infertility. However, intense exercise has also been linked to reduced sperm production and ovulation problems.
  • Taking certain prescribed medications or non-prescription drugs. Taking medications for conditions like high blood pressure, depression, and bacterial infections can negatively impact fertility; the same can be said of the habitual use of non-prescription drugs, such as marijuana, anabolic steroids, and cocaine.

How is infertility treated?

Various treatments can address infertility, including medication, surgery, artificial insemination, and assisted reproductive technology (ART). It is not uncommon for multiple treatments to be combined.

In order to determine the most fitting treatment, a doctor may consider

  • How long the individual or couple have been trying to conceive
  • The age of both partners
  • The overall health of the partners (including medical conditions)
  • Fertility test results
  • Each partner's treatment preferences

Before fertility testing, your specialist will seek to understand your sexual history and may provide suggestions to increase your likelihood of becoming pregnant. Success rates vary depending on the cause of infertility, age, and other factors.

Tests for Male Infertility

For men to be fertile, they need to produce healthy sperm that can be ejaculated into the vagina. It is important that enough sperm are motile, meaning it can move through the female reproductive tract to fertilse the egg. Various male fertility test are conducted to identify if there are problems with these processes.

Common tests for male fertility include

  • General physical assessment. This may include a genital examination to make sure there are no clear physical causes, such as a varicocele.
  • Semen analysis. A semen analysis is conducted to gain an understanding of the quantity and quality of your semen and sperm. A semen sample is typically provided through masturbation, although it may also be given by interrupting intercourse and ejaculating into a sterile container.
  • Hormone testing. You may undergo a blood test to assess your hormone levels, including testosterone.
  • Genetic testing. In some cases, genetic abnormalities can lead to infertility, and this possibility can be either confirmed or ruled out through testing.
  • Testicular biopsy. This may be done if the cause of a low sperm count is not detected by a semen analysis or blood tests. This procedure is also used to retrieve sperm for an assisted reproductive technology (ART), such as in vitro fertilisation (IVF).
  • Imaging. These tests may be appropriate under specific conditions. Imaging could include magnetic resonance imaging (MRI) of the brain and a transrectal or scrotal ultrasound.
  • Specialty testing. On rare occasions, additional tests might be carried out to assess the quality of sperm, like examining a semen sample for any DNA abnormalities.

Tests for Female Infertility

For women, getting pregnant requires the release of a healthy mature egg from the ovaries (ovulation), a clear reproductive tract that facilitates the movement of mature eggs so that they can be fertilised, and an internal environment that supports fertilisation and implantation.

Assessments of female fertility aim to identify if there are any problems with these processes and conditions. Common tests for female fertility include

  • Pelvic exam. Also called a gynaecological exam, this is a physical examination of the female reproductive system. Typically, a doctor looks at your internal and external genitalia, and may check your internal organs with a gloved hand.
  • Hormone blood tests. Hormone tests measure levels of hormones that are essential to female fertility. This includes follicle-stimulating hormone (FSH), luteinising hormone (LH), estrogen, anti-müllerian hormone (AMH), thyrotrophin (TSH), progesterone, and prolactin. It may also include testosterone, as high levels can disrupt the menstrual cycle and impact fertility.
  • Ovulation testing. To check whether the individual is ovulating, hormone levels are measured through blood tests.
  • Ovarian reserve testing. This testing method measures the number of eggs that are eligible for ovulation. It typically involves measuring hormones around day three of the menstrual cycle.
  • Imaging tests. Various imaging tests may be used to evaluate the reproductive organs and functioning. A sonohysterogram is used to check details inside the uterus. A pelvic ultrasound looks for abnormalities in the ovaries or uterus, such as structural issues, fibroids, or endometriosis. Hysterosalpingography (HSG), also called a hysteroalpingogram, is a diagnostic test to assesses the uterus and fallopian tubes' health and identify any potential blockages or issues. In HSG, a special dye is pushed through a thin tube into the uterus. Next, X-rays are taken to check if there are abnormalities with theuterine cavity and if the dye is overflowing out of the fallopian tubes.

In some cases, your specialist may recommend a standard surgical procedure, such as:

  • Hysteroscopy. A hysteroscopy is used to determine the health and functioning of the internal uterine cavity. During this minimally invasive procedure, a slender instrument with a light (also called a hysteroscope) is inserted through the vagina and into the uterus to identify possible irregularities.
  • Laparoscopy. A laparoscopy is a surgical procedure that entails creating a minor cut below the navel and inserting a slim visualisation tool to investigate the outside of the uterus, the ovaries and the fallopian tubes. This procedure may discover fallopian tube obstructions, endometriosis, scarring, and problems with the uterus and ovaries.

How is male infertility treated?

Treatment for male infertility may include the following:

  • Medications. There are particular medications that may enhance sperm count and the chances of successfully fertilising an egg. These medicines may improve how the testes function, including the quality and production of healthy sperm.
  • Surgery. If there are structural issues, such as blockages in the reproductive tract or a varicocele, surgery may be a suitable treatment that improves your odds of getting pregnant.
  • Sperm retrieval. If sperm count is low, sperm are not motile, or there are problems with ejaculation, sperm retrieval techniques can help obtain sperm.
  • Changing lifestyle factors. There are behavioural measures that can be taken to improve the likelihood of achieving pregnancy; these may include stopping certain medications, ceasing smoking, limiting the intake of alcohol, improving the timing and frequency of sexual intercourse, and exercising. Consult your doctor to learn more.

How is female infertility treated?

Treatment for female infertility may include one or a combination of the following:

  • Medication to stimulate ovulation. A number of medications, also called fertility drugs, are the primary means of treating women with ovulation disorders who are experiencing infertility. Through various medications, ovulation can be stimulated or regulated. Ask your fertility specialist about the benefits and side effects of different medication options.
  • Intrauterine insemination (IUI). IUI involves placing healthy sperm   directly into the uterus when ovulation occurs.
  • Surgery. Uterine issues, such as a uterine septum (a uterus with a wall of tissue creating two cavities) or fibroids (tumours that can grow in or on your uterus) may be addressed with an incisionless operative hysteroscopy. For conditions including endometriosis, pelvic adhesions, and larger fibroids, laparoscopy, involving small incisions, may be the more appropriate technique.
  • Changing lifestyle factors. Just as with men, the likelihood of getting pregnant may increase by discontinuing certain medications, ceasing smoking, limiting the intake of alcohol, improving the timing and frequency of sexual intercourse, and exercising.

Why is it important to address infertility?

Infertility can have a huge impact on mental health and well-being. In addition, being unable to conceive may point to a medical condition or physical health issue that can negatively impact quality of life. By addressing reproductive health and fertility issues, couples and individuals can not only improve their chances of getting pregnant, they can also improve their overall health.

In general, even if you are not trying to conceive, gaining an understanding of your circumstances and potential ways to address concerns may help you to feel empowered regarding your health and your reproductive choices.

When should I see a specialist?

You may want to consider seeing a fertility specialist if:

  • You and your partner cannot conceive within 12 months of having regular unprotected sex during the fertile window (six days up to and including ovulation)
  • You are a woman over the age of 35 and have not gotten pregnant after six months of regular unprotected sex
  • You are a woman younger than 35 with a family history of early menopause or a history of cancer treatments
  • You have a prior health history that increases your risk of infertility. For men, this may include damage to the testicles or being diagnosed with a genetic or hormonal disorder. For women, this may include being diagnosed with a reproductive disorder or having prior surgery on the reproductive tract.
  • You are experiencing signs of reproductive disfunction, such as irregular menstrual cycles or difficulty ejaculating.

Takeaway

Infertility is the inability to conceive after engaging in regular and unprotected sexual activity during the fertility window for at least one year. Both males and females experience fertility issues, and infertility tends to involve both equally. It can be difficult to know the exact cause of infertility, and unexplained infertility is common. Lifestyle factors, such as excessively drinking alcohol, smoking cigarettes, being overweight, and being exposed to environmental toxins, are associated with higher rates of infertility. Internal factors, such as stress and anxiety, may also impact fertility.

Many infertility treatments are available today, such as medication, assisted reproductive technology, and surgery. If you are experiencing signs of reproductive dysfunction, have a prior health history that increases your risk of infertility, or have been trying to conceive without success, you may want to consult a fertility specialist for evaluation and treatment options.

Our compassionate team of fertility specialists can evaluate the possible cause of infertility and help you find treatment options that fit you. Reserve your spot for a free consultation today.