How long do couples usually take to get pregnant?

80-90% of normal fertile couples will conceive within a year of regular unprotected intercourse. This rises to 95% after 2 years of unprotected intercourse. Infertility is usually defined as an inability to conceive after a minimum of 12 months of unprotected intercourse. Doctors would not usually investigate for a fertility problem unless you had been trying unsuccessfully for at least a year. This is because many normal couples take at least this long to conceive.

How many couples have difficulty conceiving?

Fertility problems affect around 1 in every 6 couples.

Why do some couples have difficulty conceiving?

The main problems that underlie difficulty conceiving can be due to problems in producing eggs (25%), problems with the fallopian tubes preventing transport of the egg (20%), or problems with the quantity or quality of the sperm (30%). Sometimes, in around 15% of couples, there may be more than one factor. In most other cases no obvious reason is found and this is termed "unexplained" infertility (25%). When investigating infertility it is essential to assess the couple together. Other factors associated with fertility problems include Being underweight or overweight, rapid weight loss and smoking.

Is age important?

Age of the woman is important as fertility wanes especially after 40 years of age, but age has much less of an effect with regard to male fertility. Women over 40 are likely to produce fewer eggs. In addition, the eggs she produces may not have as good ability to implant into the womb as they did at a younger age. Miscarriage is also increased in women over 40 and there is also an increased risk of other pregnancy complications including the baby being affected by Down’s syndrome (cross ref to antenatal tests).

We have been trying for a baby for more than a year, what should we do?

You should seek medical advice and ideally you should be seen together. Remember it is common for causes of infertility to be found in both partners. The doctor will take a detailed history from you both. The information which the doctor will want to find out will include age, how long you have been trying to conceive, how often you have intercourse, previous contraception, whether you have any problems with intercourse, smoking and alcohol use, the presence of chronic medical conditions or long term medication, and details of previous pregnancies for you both. You will be asked about menstrual problems and any history of pelvic infection or abdominal surgery. Your partner will be asked about his occupation, any past medical problems, surgical operations or trauma to the testicles and any infections affecting the genitals including mumps. He will also be asked about any regular medication as this can sometimes upset sperm function and about any sexual difficulty. The Doctor will also want to know about smoking and alcohol consumption. You both may be examined.

What will the doctor tell us to do?

The doctor will tell you if there are any obvious problems and whether a specialist referral is required. He/She will give general advice such as the need to take folic acid, stop smoking, cut down or stop drinking alcohol, and check if you are immune to Rubella. It may be worth checking whether you are anaemic. It may also be useful to check if you carry hepatitis or HIV, as these tests are needed prior to assisted conception as these conditions may have implications for the baby. If you are overweight the doctor will advise about the need to reduce weight or limit weight gain. It is not usually routine to advise you to use temperature charts or ovulation prediction kits in the first instance as there is little evidence to show that they improve success over regular intercourse occurring every couple of days throughout the cycle.

What investigations will be performed?

Your initial investigations can be performed by a family doctor, but more detailed assessment and treatment requires referral to a specialist. There are 3 key questions to be answered. Do you produce an egg (ovulate) regularly? Is your partners’ sperm production satisfactory? Is there any problem with your Fallopian tubes that will prevent transport of the egg?

How is Ovulation assessed?

If you have regular periods with a cycle of 21 to 35 days this suggests that you are ovulating regularly. If you have Mittelschmerz (mid-cycle pain associated with ovulation), changes in your cervical mucus and increased temperature mid cycle these features also suggest that you are ovulating (cross ref to menstrual cycle and conception). The key medical investigation is to measure the concentration of a hormone called progesterone in a blood sample taken 7 days before your expected period is due. If you have an irregular cycle then several samples may be required, each taken a few days apart. Progesterone is only produced in high quantities after ovulation. So a high progesterone leve means that you have ovulated. If you not ovulating then further hormonal assessments will be required to identify the cause.

How are sperm problems assessed?

The male partner will be asked to produce a semen sample by masturbation after abstaining from intercourse for at least 2 days. He should not collect the sample in a condom – most condoms have spermicidal lubricants that will make analysis impossible. Do not collect the sample by coitus interruptus (withdrawal during intercourse) as much of the sample can be lost – remember that there is often some semen released prior to ejaculation proper which the man may not be aware of. The sample should be collected in a wide mouthed plastic specimen pot. The semen should be promptly transported, avoiding extremes of temperature, to the laboratory. As there is marked variation in semen from day to day and week to week, at least two specimens should be assessed. The normal semen sample has a volume of 2.5 ml to 5 ml with more than 20 million sperm in each millilitre. Fifty per cent of the sperm cells should be able to move forward and more than 15% of the sperm cells should be have a normal form. As it takes around 70 days for sperm to mature it is usual to allow 2 to 3 months between samples so that any temporary upset in sperm production will be over

How is the function of the Fallopian tubes assessed?

Several methods are available to assess tubal function. Diagnostic laparoscopy is considered by many gynaecologists as the investigation of choice. It usually requires general anaesthesia. A laparoscope (a telescope like instrument) is inserted below the navel (umbilicus) so that the surgeon can see the womb (uterus), Fallopian tubes and ovaries. Blue dye is injected through the cervix using an instrument placed in the cervix through the vagina. This dye flows through the womb and tubes and if the tubes are open spills into the abdomen. The surgeon can watch the progress and spill of dye from within the abdomen with the laparoscope.

X-ray assessment can also be used. Special dye that appears white on an X-Ray is injected through the cervix An X-ray is then taken and the outline of the womb and tubes will be seen. If the dye is seen spilling into the abdomen on X-ray then the tube is open on that side. There is also a similar technique using ultrasound.

As infection is the commonest cause of tubal damage a test to look for evidence of past or current infection, which can affect the tubes, may also be performed.

If I am not ovulating how can this be treated?

The treatment of disturbance of ovulation depends on the reason causing the disturbance. Most commonly you will have irregular or infrequent periods due to a hormonal disturbance affecting the ability of the ovary to produce eggs and an appropriate balance of hormone production. Sometimes the cause is not directly linked to the hormones controlling your ovary, but through other hormones that have a knock on effect. For example upsets in your thyroid or adrenal glands can also disturb the ovary. Obviously if you have specific problems such as thyroid disease this should be treated. However, most women who do not ovulate regularly have a disturbance in the balance of hormones controlling the ovary. This is treated with medications that stimulate the ovary to produce eggs. Success of the treatment in inducing ovulation can be check by measuring progesterone levels in your blood. One problem with this therapy is that sometimes the ovaries will produce more than one egg in response to stimulation so that there is an increased risk of twins or even triplets. Where this is considered a significant risk, the response of the ovary to the drugs will be monitored by the gynaecologist using techniques such as blood hormone measurement or ultrasound to visualise the eggs developing on the ovary.

I have a problem with my sperm count, how is this treated?

The management of a man with no sperm in his seminal fluid is to determine whether there is a problem with production or whether the tubes connecting the testicles to the penis are blocked. Blockage can be treated surgically. If absolutely no sperm are being produced this implies a problem with the testicles or hormones controlling sperm production and specialist help is required. It is however very rare for a man to have absolutely no sperm. More commonly the sperm count will be low or there will be reduced sperm function, such as reduced ability of the sperm to move. There is no effective treatment proven to increase male fertility where the sperm function is impaired. The treatment is usually by assisted conception (see later) to help you conceive, although conception may still occur spontaneously. The alternative is to use semen from a donor who is usually anonymous and who has been checked for health problems and infections. The donor can be matched for physical characteristics with the male partner. Donor sperm is usually stored frozen in banks. At the woman’s fertile time the sperm is defrosted and injected into either the vagina around the cervix, or directly into the womb. The decision to embark on this line of treatment requires careful consideration and counselling from specialist clinics.

What is the treatment if my Fallopian Tubes are blocked?

Infection in the womb and Fallopian tubes or abdominal problems, such as appendicitis, that are associated with infection and inflammation in the pelvis can lead to damage to the Fallopian tubes. This will block the access of the sperm to the egg. Infection can sometimes complicate miscarriage or can occur after pregnancy. In the worst cases both tubes are blocked. Sometimes the ovaries are covered by adhesions, preventing release of the egg. One episode of pelvic infection can lead to infertility in up to 15% of women. The more episodes of infection a woman has had the greater the risk of tubal damage. It is therefore important that pelvic infection is treated promptly The best treatment if you have tubal blockage is in vitro fertilisation (IVF). Alternatively, you could have tubal surgery to release the blockage, but this is not usually as effective as IVF. In addition, the greater the level of tubal damage the lower the likelihood of successful surgery and subsequent pregnancy.

What is unexplained infertility?

Unexplained infertility is diagnosed after the other causes of infertility have been excluded. It accounts for about a quarter of all cases of infertility. If you have unexplained infertility and have been trying to get pregnant for less than three years, your chance of falling pregnant without treatment is as much as 5-10% per month. If you have unexplained infertility and have been trying to get pregnant for more than 3 years your chance of getting pregnancy without treatment is only around 1-2% each month, so you will probably want to consider specialist help treatment as soon as possible.

What treatment can we get for unexplained fertility?

For younger women a ‘wait and see’ policy can be adopted as some will conceive naturally, particularly if you have been trying to get pregnant for less than 3 years. Where you are older or the infertility has been present for more than 3 years other options should be considered. The treatments are to stimulate your ovaries with drugs to produce more eggs or use assisted conception techniques like IVF.

What is assisted conception?

Assisted conception is the use of techniques to bring sperm and egg together and so facilitate pregnancy. Many countries regulate assisted conception. In the UK it is regulated by the Human Fertilisation and Embryology Authority (HFEA). The main techniques are in vitro fertilisation (IVF), intracytoplasmic sperm injection (ICSI) and donor insemination (DI).

What is In vitro fertilisation (IVF)?

What is intracytoplasmic sperm injection (ICSI)?

ICSI has revolutionised the treatment of male factor infertility. Until ICSI was developed the treatment of male factor infertility was very limited. ICSI is the direct injection of a single sperm into the egg. As with IVF eggs are obtained by stimulation of the ovaries with hormones called gonadotrophins to stimulate multiple egg production. The response of the ovary is checked by ultrasound, and sometimes also by measuring hormone levels. When the eggs have reached maturity they are retrieved by passing a needle through the vagina into the ovary with the woman under sedation. The needle is guided in to position using an ultrasound scan, then the eggs are sucked down the needle and collected. This is the best treatment where the sperm count is very low or where the sperm fail to move properly. Where there is an obstruction to sperm getting to the penis, sperm can be taken surgically from the testicles and used in ICSI. Thus it is a technique of great value when infertility is associated with sperm problems. Around 70% of eggs injected with a sperm will fertilise successfully with ICSI. Like IVF, up to two fertilised eggs are put into the womb 2 days after the eggs have been collected and fertilised.

What is donor insemination (DI)?

In DI, donated semen is placed at the cervix or inside the womb at the time of ovulation. It can be used where the male partner has no sperm production or severe sperm problems. The semen comes from a donor who is usually anonymous and who has been checked for health problems and infections. The donor can be matched for physical characteristics with the male partner. Donor sperm is usually stored frozen in special sperm banks. If the woman has more than one pregnancy with DI then the same donor can be used.

First of all you should remember that normal conception rates are only around 20% per month on average. If you compare this with assisted conception techniques you can see that these techniques are often as good or sometimes better than natural rates! You should also remember that the woman’s age is important both in natural and assisted conception, and that fertility starts to fall after age 35 becoming quite marked after age 40. Results vary from centre to centre and also depend on the type of patients treated. In the UK currently the overall live birth rate after IVF and ICSI is around 24% per embryo replaced. The rate is slightly higher, around 27%, where the woman is under 38 years of age. With donor insemination the live birth rate is around 11-12% for each treatment cycle.

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