infertility treatment

What is infertility? Causes, Symptoms and Treatment Options

What is Infertility ?

Infertility is commonly defined as the inability to achieve pregnancy after a year of consistent sexual intercourse without using contraception. The likelihood of pregnancy with regular, unprotected intercourse is as follows:

  • 50% of couples achieve pregnancy within 3 months
  • 75% within 6 months
  • 90% within 1 year

Up to one in five couples do not conceive within a year of trying, classifying them as having infertility. However, among couples who have not conceived after a year of trying, more than 60% eventually achieve pregnancy, with or without medical intervention.

Causes of Infertility

Infertility can stem from issues affecting the man, the woman, or both:

  • Problems with sperm (in more than 35% of couples)
  • Issues with the fallopian tubes and pelvic abnormalities (in approximately 30%)
  • Ovulation problems (in around 20%)
  • Problems related to cervical mucus (in 5% or fewer)
  • Unidentified factors (in about 10%)

Maximizing Conception Chances by Estimating Ovulation

To enhance the chances of conception, couples should engage in frequent intercourse during the 6 days leading up to, especially the 3 days before, ovulation. Ovulation typically occurs in the middle of the menstrual cycle, approximately 14 days before the onset of the woman’s next period.  It remains unclear whether predicting ovulation increases the chances of pregnancy for couples who engage in regular intercourse. Nonetheless, it can be beneficial for couples who do not have frequent intercourse to identify the optimal time for sexual activity.

Common methods women can employ to predict ovulation are:

  1. Home Ovulation Prediction Kits: These kits are considered one of the most accurate methods for home use. They detect an increase in luteinizing hormone in urine, which stimulates ovulation. This hormone surge usually happens 24 to 36 hours before ovulation. Women need to perform the test on several consecutive days, so these kits typically contain five to seven sticks. The sticks can either be held under a stream of urine or dipped into urine collected in a clean, preferably sterile, container.
  2. Basal Body Temperature (BBT) Measurement: Women with regular menstrual cycles can estimate ovulation by measuring their temperature every morning before getting out of bed. A decrease indicates impending ovulation, while an increase of 0.9°F (0.5°C) or more suggests ovulation has recently occurred. However, this method is time-consuming and lacks precision. At best, it predicts ovulation within 2 days after it occurs.
  3. Ovulation Calculator: Women can track their cycle and may use Ovulation Calculator to help identify peak fertile days. Ovulation Calculator on this web site uses the results from multiple studies and precisely calculates the chances of ovulation on each day of the cycle. It gives range of days in which women are most likely to ovulate.

Lifestyle and Fertility

Excessive caffeine and tobacco use in women may adversely affect fertility and should be avoided. While there is no conclusive evidence linking high coffee consumption to reduced fertility, some data suggest that women who consume more than 5 to 6 cups of coffee per day may experience longer conception times.

Additionally, certain studies have indicated that men over the age of 45 may exhibit lower fertility compared to younger men.

Diagnosis of Infertility

  • Medical Evaluation: Diagnosis of infertility typically involves a comprehensive evaluation by a healthcare provider.
  • Diagnostic Tests: A range of tests may be conducted, depending on the suspected causes of infertility.

The assessment of infertility issues necessitates a thorough examination of both partners. Usually, this assessment is performed after a minimum of 1 year of attempting to conceive. However, it may occur sooner in the following cases:

  • If the woman is over 35 years old (typically after 6 months of attempting pregnancy).
  • If the woman experiences infrequent menstrual periods (fewer than nine times a year).
  • If the woman has a known abnormality in the uterus, fallopian tubes, or ovaries.
  • If problems with sperm are identified or suspected in the male partner.

Age is a significant factor, especially for women. As women age, the likelihood of becoming pregnant diminishes, and the risk of pregnancy complications increases. Fertility may start to decline around the age of 35, and after the age of 40, achieving pregnancy becomes even more challenging.

Specific diagnostic tests are performed based on the suspected causes, including:

  • For issues related to eggs: Blood tests to measure hormones involved in ovulation, such as follicle-stimulating hormone, luteinizing hormone and progesterone. Other tests like AMH levels may also be done in age related issues.
  • For ovulation problems: vaginal Ultrasonography to assess ovulation and antral follicle count .
  • For sperm disorders: Semen analysis.

Treatment of Infertility

  • Addressing the Underlying Cause: Treatment aims to address the root cause of infertility.
  • Medications: In some cases, fertility medications may be prescribed.
  • Surgical Interventions for Fertility
  • Assisted Reproductive Technologies: Advanced techniques like in vitro fertilization (IVF) or intrauterine insemination may be recommended.
  • Stress Management: Measures to reduce stress, including counseling and support, may be part of the treatment plan.

The objectives of infertility treatment are as follows:

  • To address the underlying cause of infertility, if possible.
  • To increase the likelihood of conception.
  • To shorten the time required to achieve pregnancy.

Common fertility medicines include:

  • Clomifene – helps in the monthly release of an egg (ovulation) in women who do not ovulate regularly or do not ovulate at all
  • Letrozole – an alternative to clomifene that may be offered if you have ovulation problems
  • Metformin – is particularly beneficial for women who have polycystic ovary syndrome (PCOS)
  • Gonadotrophins – can help stimulate ovulation in women
  • Gonadotrophin – releasing hormone and dopamine agonists – other types of medicine prescribed to encourage ovulation in women.

Some of these medicines may cause side effects, such as nausea, vomiting, headaches and hot flushes. Women prescribed fertility medications like clomiphene, letrozole, or human gonadotropins, which stimulate the maturation and release of multiple eggs. These medications are particularly helpful for women with ovulation problems but may increase the likelihood of multiple pregnancies.

Surgical Interventions for Fertility

There exist various surgical procedures designed to address fertility issues and enhance reproductive chances.

Fallopian Tube Surgery

In instances where the fallopian tubes are obstructed or scarred, surgical intervention becomes necessary for their repair. Surgery can effectively alleviate the scar tissue within the fallopian tubes, facilitating smoother passage for eggs. The outcome of this procedure hinges on the degree of damage sustained by the fallopian tubes. Potential complications from tubal surgery include ectopic pregnancies, wherein the fertilized egg implants outside the uterus.

Managing Endometriosis, Fibroids, and PCOS

Endometriosis entails the growth of tissue resembling the uterine lining in locations beyond the uterus.Laparoscopic surgery is a common method employed for treating endometriosis, involving the elimination or destruction of fluid-filled cysts.This surgical approach can also be used to eliminate submucosal fibroids, which are small growths within the uterus.

For individuals diagnosed with polycystic ovary syndrome (PCOS), laparoscopic ovarian drilling, a minor surgical procedure, can be considered if prior ovulation medications have proven ineffective. This technique entails the use of heat or laser to target a portion of the ovary.

Addressing Epididymal Blockage and Sperm Retrieval Surgery

The epididymis, a coiled structure in the testicles, plays a crucial role in sperm storage and transportation. In some cases, the epididymis may become obstructed, impeding the normal ejaculation of sperm. To rectify this issue and address infertility, surgical procedures are available. For individuals who meet the following criteria:

  • Have an obstruction preventing sperm release
  • Were born without the sperm drainage tube (vas deferens)
  • Have undergone a vasectomy or experienced a failed vasectomy reversal

Surgical sperm extraction becomes a viable option. This procedure is typically performed under local anesthesia, although general anesthesia may be employed depending on the specific procedure. It is usually conducted as an outpatient procedure. Immediate feedback on the quality of collected tissue or sperm is provided, with any sperm being frozen and stored for potential future use.

Assisted reproductive technologies

Alternatively, healthcare providers may recommend assisted reproductive technologies, including:

  • Intrauterine Insemination: A procedure that selects the most active sperm and places them directly into the uterus.
  • In Vitro Fertilization (IVF): A process that involves ovarian stimulation, retrieval of mature eggs, fertilization with sperm in a controlled environment, embryo development in culture, and implantation of one or more embryos into the woman’s uterus. These methods can result in multiple pregnancies.
  • Intracytoplasmic sperm injection(ICSI):A process in which sperm is injected into the egg to create an embryo that is then implanted into the woman’s uterus in cases of male factor infertility
  • Sperm or egg donation; If you or your partner has an infertility problem, you may be able to receive eggs or sperm from a donor to help you conceive. Treatment with donor eggs is usually done using IVF.
  • Stem cell treatment; A promising new technology in which a person’s own stem cells are used to treat male and female infertility in cases of low sperm count or absent sperms in males and low ovarian reserve in females.

Coping with the Emotional Impact

While undergoing infertility treatment, individuals and couples may experience a range of emotions, including frustration, stress, feelings of inadequacy, and guilt. They may oscillate between hope and despair and may find it challenging to communicate their emotions. The emotional stress can lead to fatigue, anxiety, sleep or eating disturbances, and difficulty concentrating. Additionally, the financial and time commitments associated with diagnosis and treatment can strain relationships.

These challenges can be alleviated through active involvement of both partners in the treatment process and by providing them with comprehensive information. Knowing the chances of success and understanding that treatment may not always yield results or continue indefinitely can help couples cope with the emotional strain.

Additional information can include:

  • The likelihood of treatment success
  • Details about the treatment, including timeframes and costs
  • When to consider discontinuing treatment.
  • When to seek a second opinion.
  • When to explore alternatives like adoption or surrogate pregnancy.

For instance, if pregnancy has not occurred after 3 years of trying or after 2 years of infertility treatment, the likelihood of pregnancy is considerably low. Ideally, couples should have this information before beginning treatment.


Dr Sobia Mohyuddin

MCPS, FCPS, MRCOG, Consultant Obstetrics & Gynaecology

Doctor Sobia Mohyuddin is a highly skilled and experienced Obstetrician and Gynecologist, with 25 years of training and experience in renowned, large institutions. She holds the position of Associate Professor and Fellow at the College of Physicians and Surgeons Pakistan. She is also a member of the Royal College of Obstetricians and Gynecologists (UK).