Infertility

Definition | Causes | Risk Factors | Investigations | Management | References

Definition

Infertility is defined as the inability to conceive after one year of regular, unprotected sexual intercourse. It can be due to factors affecting either the male or female partner, or a combination of both.

Causes

Infertility can be caused by a variety of factors, including:

Female Factors:

• Ovulatory Disorders: Conditions such as polycystic ovary syndrome (PCOS), hyperprolactinaemia, or thyroid dysfunction can affect ovulation.
• Tubal Damage: Damage to the fallopian tubes due to infections (e.g., pelvic inflammatory disease), surgery, or endometriosis can prevent the egg and sperm from meeting.
• Uterine Abnormalities: Congenital abnormalities, fibroids, or polyps can interfere with implantation.
• Cervical Factors: Cervical mucus abnormalities or structural issues can hinder sperm penetration.
• Age: Female fertility declines with age, particularly after the age of 35.

Male Factors:

• Sperm Disorders: Low sperm count, poor motility, or abnormal morphology can reduce fertility.
• Testicular Disorders: Conditions such as varicocele, infections, or trauma can impair sperm production.
• Ejaculatory Disorders: Retrograde ejaculation or erectile dysfunction can prevent sperm from reaching the egg.
• Hormonal Imbalances: Disorders of the hypothalamus or pituitary gland can affect sperm production.

Combined Factors:

• Both partners may have contributing factors that result in infertility.
• Unexplained infertility occurs when no specific cause is identified despite thorough investigation.

Risk Factors

• Advanced maternal age (over 35 years).
• History of sexually transmitted infections (STIs).
• Smoking or excessive alcohol consumption.
• Obesity or being underweight.
• Exposure to environmental toxins or radiation.
• Previous pelvic or testicular surgery.

Investigations

• History and Physical Examination: A detailed history and examination of both partners to identify potential causes of infertility.
• Ovulation Testing: Assessment of ovulation through methods such as basal body temperature charting, luteinizing hormone (LH) testing, or serum progesterone levels.
• Semen Analysis: Evaluation of sperm count, motility, and morphology to assess male fertility.
• Hormone Testing: Measurement of hormones such as FSH, LH, prolactin, and thyroid hormones to assess ovarian function and endocrine disorders.
• Imaging Studies: Ultrasound of the pelvis to evaluate the uterus, ovaries, and fallopian tubes. Hysterosalpingography (HSG) may be used to assess tubal patency.
• Laparoscopy: A surgical procedure to directly visualize the pelvic organs, often used in cases of suspected endometriosis or tubal damage.

Management

General Management:

• Lifestyle Modifications: Encourage weight management, smoking cessation, and reduction of alcohol intake.
• Timing of Intercourse: Advise couples to have regular, unprotected intercourse around the time of ovulation.

Specific Treatments:

• Ovulation Induction: Medications such as clomiphene citrate or gonadotropins may be used to stimulate ovulation in women with ovulatory disorders.
• Intrauterine Insemination (IUI): Sperm is directly inserted into the uterus around the time of ovulation, often used in cases of mild male infertility or unexplained infertility.
• In Vitro Fertilisation (IVF): Eggs are fertilised outside the body and the resulting embryos are transferred into the uterus. IVF is often used in cases of tubal damage, severe male infertility, or unexplained infertility.
• Surgery: Surgical correction of anatomical abnormalities, such as removal of fibroids, treatment of endometriosis, or repair of varicocele, may be indicated in some cases.

Referral:

• Refer couples to a fertility specialist or reproductive endocrinologist if initial investigations and treatments in primary care are unsuccessful.
• Consider referral to a specialist if there are complex factors involved, such as severe male infertility, or if assisted reproductive techniques such as IVF are being considered.

References

1. National Institute for Health and Care Excellence (NICE) (2021). Fertility problems: assessment and treatment. Available at: https://www.nice.org.uk/guidance/cg156
2. Royal College of Obstetricians and Gynaecologists (2020). Fertility assessment and treatment for people with fertility problems. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg69/
3. British Fertility Society (2020). Guidelines for the management of infertility. Available at: https://www.britishfertilitysociety.org.uk/clinical-guidelines/
4. NHS (2022). Infertility. Available at: https://www.nhs.uk/conditions/infertility/

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