For a woman, creating a baby is complex; there are many stages and much is involved. With all this complexity, there are many possible causes of female infertility; it’s a very complicated problem. In fact the issues involved with female infertility are far more complex than male infertility.
Even with many possible causes, there are some that we see quite regularly, these include:
There are many causes of anovulation (the absence of ovulation) and a range of symptoms. Some of the causes are treatable with drugs and sometimes lifestyle changes. Others are not treatable and pregnancy may only be possible with the help of an egg donor.
Some treatable causes are:
- Hypothalmic anovulation – caused by exercise, stress and/or weight loss
- Hyperprolactinemia – raised levels of prolactin, a pituitary hormone
- Polycystic ovarian syndrome (PCOS).
Blocked fallopian tubes
Tubes can be blocked for a number of reasons:
- Blocked from birth (congenital tubal obstruction)
- Intentional tying or clipping (to prevent pregnancy)
- Accidental damage following other surgery e.g. colectomy
- Severe endometriosis Inflammation (salpingitis).
Of these, the last is by far the most common.
Inflammation of the fallopian tubes can occur from the inside, that is, from the uterus, as is the case with sexually transmitted diseases such as gonorrhoea or chlamydia. It can also come from outside the tube by the spread of infection from another organ such as the appendix. When this happens, the tube is often damaged by adhesions, where two damaged surfaces actually join together. Adhesions can also occur after pelvic surgery or as a result of endometriosis. Adhesions can obstruct in a number of ways – by separating the ovary and tube with new tissue or by blocking the outer end of the tube. In many cases, microsurgery can be helpful in clearing the blockage.
Hydrosalpinx and pyosalpinx
A hydrosalpinx is a particular type of tubal blockage in which the tube is obstructed near its fimbrial end. The tube becomes filled with clear watery fluid. Sometimes after IVF the rise in progesterone causes the tube to relax and this fluid can be passed into the uterus, washing out the transferred embryo. This process accounts for quite a few cases of persistent IVF failure.
A pyosalpinx is an acutely inflamed blocked tube filled with pus. It sometimes subsides with antibiotics, becoming a hydrosalpinx. Otherwise it can rupture and form an abscess in the pelvis, much like a burst appendix, and then requires an operation to drain both it and the abscess.
Endometriosis occurs when material similar to the lining of the uterus begins to grow outside the uterus. It is quite a common disorder, especially in women over 30 who have had no children. It may account for as many as one in 15 cases of infertility.
Severe endometriosis can distort the tubes and ovaries so much that it has a profound effect on fertility. It can also stimulate the body’s resistance to foreign material, which can destroy sperm before it has a chance to reach the egg. Recent research is suggesting that endometriosis may also produce mucus that blocks the egg from entering the fallopian tube in the first place.
Endometriosis is usually confirmed by laparoscopy (looking inside the abdominal cavity through a small incision in the navel) and can often be treated at the same time. It can also be treated by non-surgical methods, such as hormone control.
These treatments can help to alleviate the symptoms of endometriosis, but because they prevent ovulation they will not improve fertility while the drugs are being taken or after they are ceased. Younger women, for whom getting pregnant is not their first priority, might choose this treatment for long-term control.
One of Sydney IVF’s fertility specialists, Dr Geoffrey Reid has an excellent site with more endometriosis information.
Fibroids and polyps in the uterus
Fibroids are benign lumps of tissue growing in or on the myometrium (the wall of the uterus surrounding the endometrium). The closer they are to the endometrium, the more likely they are to cause symptoms such as heavy bleeding, dysmenorrhea and infertility.
Male fertility seems less complicated than female fertility simply because the male is responsible for fewer stages in the process of creating a baby. Essentially, male fertility is largely dependent on the state of the sperm. Sperm number, morphology and motility are important factors.
Usually, male infertility is not treatable except with assisted conception. There will be a decrease in fertility if the sperm are:
- Not being produced in adequate numbers (or not at all)
- Being produced, but facing an obstruction that prevents them from reaching the outside world
- Being produced, but not swimming very well
- Stimulating antibody production in either partner by causing an allergic reaction.
Some of these causes can be treated surgically, but in most cases assisted conception or donor sperm are the best options.
The semen analysis
Testing for male infertility is a very straightforward process and it’s another service we can offer. A semen analysis will examine three factors:
- Sperm count – the number of sperm per ml of ejaculate
- Sperm motility – the sperm’s ability to swim
- Sperm morphology – the shape of the sperm.
A ‘normal’ sperm count will have:
- An overall volume of at least 2 ml.
- A sperm density of more than 20 million sperm per ml
- A motility of 50% or better (the percentage of sperm cells present that are moving)
- A proportion of normal forms of 4% or greater
That is not to say that couples will not get pregnant, even with a much lower count (after all, it just takes one sperm), just that the chances of pregnancy are reduced by low sperm counts or sperm that do not swim well.
The complete absence of sperm in the ejaculate (azoospermia) can be either because of a blockage in the epididymis or vas deferens, or a problem with the actual production of sperm in the testicles. A blockage can sometimes be overcome by microsurgery, and even if sperm are not being produced, it may be possible to surgically extract enough sperm cells from the testes to use for ICSI.
If all else fails, using donated sperm can be an option.
Morphology and motility
Abnormal morphology (what the sperm looks like) and poor motility can prevent the sperm from reaching the egg. The sperm need motility to be able to swim well and survive for a number of hours in the female reproductive tract. If they do meet, abnormal-looking sperm might be incapable of fertilisation.
Anti sperm antibodies
Antibodies are the body’s natural defence against foreign objects. They are part of the immune system. Sometimes a woman’s immune system can recognise her partner’s sperm as foreign and develop antibodies against them. Men can even develop antibodies against their own sperm! This is most common in men who have had a vasectomy reversal.
The antibodies can attack the sperm by paralysing them, causing them to clump together or coating them so that they can’t fertilise the egg. Antibodies will be found in the semen, the cervical mucus, or either partner’s blood.
Tests at Superior A.R.T.
The following male fertility tests can be performed at Superior A.R.T.
Semen analysis – tests the overall appearance, acidity/alkalinity and volume of the semen, measures the sperm concentration, motility and vitality, and assesses morphology.
Assisted conception treatments
In vitro fertilisation – IVF can be effective for lowered sperm counts because the sperm and egg are brought together in the small space of a special plastic dish, improving the chance of fertilisation.
Sperm microinjection – Since the development of ICSI (intra-cytoplasmic sperm injection), fertilisation can be achieved even when there are hardly any sperm in the ejaculate. A single sperm is injected directly into the body (cytoplasm) of the egg, bypassing most of the barriers to fertilisation.
Surgical sperm extraction – When there are no sperm in the ejaculate or if the sperm are severely affected by antisperm antibodies, sperm can now be retrieved directly from the testes (testicular sperm extraction – TESE) or the epididymis, which joins the testis to the vas deferens (percutaneous epididymal sperm aspiration – PESA). PESA or TESE can be used in conjunction with ICSI to achieve fertilisation, even when there is only one sperm per egg! Immature and poorly swimming sperm are also usable with ICSI because they don’t need to swim to the egg in order to fertilise it.
Age & infertility
Female age is one infertility factor that IVF clinics can do little to combat without resorting to using donor eggs.
Why is age so important?
There are several reasons why live births become rare as women move through the age of 40:
- The chance of experiencing some fertility decreasing conditions, such as endometriosis or fibroids increases with age.
- It is recognised that the occurrence of abnormal fetuses is much higher among older women. One of the best known is the chromosomal abnormality that results in Down syndrome, you’ll find more information on the subject below. Chromosomal abnormalities are major contributors in the increased rate of miscarriage among older women.
- All the energy required for an embryo to keep dividing and growing comes from the egg, in little packets called mitochondria. As women get older, their eggs contain fewer and fewer healthy mitochondria, and have less energy available. The fetus will produce its own mitochondria once it reaches a certain point in its development, but if there is not enough energy to reach that point, development will stall, resulting in failure to fertilise, failure to implant, failure to divide, or early miscarriage.
- If periods are absent or irregular, ovulation (release of eggs from the ovaries) is often absent or irregular too. An absence of ovulation will result in complete infertility. Ovulation can be corrected in some patients with hormones or drugs. If there are no eggs in the ovaries that respond to drug treatment, the only solution for pregnancy is to use donated eggs or embryos.
- An obstruction between the vagina and the ovary. The most common site of obstruction is the fallopian tubes, and it will prevent fertilisation, even when sperm production and ovulation are normal. Blocked fallopian tubes can be treated with microsurgery, or otherwise with assisted conception.
- Endometriosis. This is a common condition where tissue like the lining of the uterus (the endometrium) is found in places outside the uterus. Its presence can hamper a number of events important to conception and implantation of the embryo in the uterus, resulting in subfertility. Treatment can be with drugs, with surgery, or with assisted conception.
The age factor
As you can see from the graph below, by age 36 a normal woman’s chance of conceiving per month is decreased by half. The downward slope continues until by age 45 the average natural fertility rate per month is approximately 1%.
Aside from a physical condition that can cause infertility, genetics can also play a part. Genetic abnormalities can affect an embryo’s ability to grow, implant and develop, causing infertility or miscarriage.
Genetic mistakes can occur during a number of stages of embryo development. In many cases, these mistakes will cause an embryo to cease development and miscarry – often before the mother even knows she is pregnant.
In other cases, such as with Down syndrome, the abnormality may not be severe enough to prevent the fetus developing and being born, although they will result in a child with disabilities.
Down syndrome (named after English physician John Langdon Down) is most commonly caused by an error occurring when the egg or sperm cell divides. At that time, extra material from chromosome 21 is given to the embryo. As the embryo develops, this extra chromosome is replicated in every cell, causing abnormal development.
This kind of genetic abnormality is called a trisomy (tri = three, somy = chromosomes) and you will often hear Down syndrome referred to as trisomy 21. Trisomies of other chromosomes do happen, but most result in fetuses too abnormal to develop.
Coping with infertility
When infertility dawns it’s a devastating shock. It can cause our foreign, illogical thought about ourselves to become lodged in our minds and refuses to leave, hurting us when we are at our most depressed and vulnerable. It can also place immense strain on relationships.
Here’s what you should know:
Women and men generally differ in the way they respond to the strain of infertility. Women bear the brunt of tests and treatment, and are more likely to want to talk openly about their feelings. To men, talking a lot about the feelings infertility brings can seem like a waste of time, because it doesn’t change the situation. Through all this, a destructive pattern of non-communication and miscommunication can develop between you and your partner. Seek help and fresh understanding through counselling – before this pattern develops.
Family and friends – Sex generally, and not getting pregnant in particular, is such a personal and private matter that it might seem too painful to you and your partner to tell others. Before awareness of your infertility reaches friends and relations, their remarks about you not having children can be hurtful.
Loss of personal power – It is common to question your own feelings about your sexuality. You may feel that you’re not whole. You may feel angry with your body, which doesn’t seem to do anything right. You might sometimes feel you are going mad. Such feelings are normal and counselling can help. Once such imaginings are out in the open – in the safety of a counselling session with a true professional – they have less power over you.
Here’s what you can do:
Live for the present – Make the most of the resources you have. It may be cold comfort, but when it comes to time and finances, you are in a better position to do things spontaneously than couples bound down with kids are.
Plan your life – Decide ahead which months will be set aside for assisted conception or infertility treatment, which months for pleasure. With a plan of action that stretches for months ahead you’re less likely to feel the bumps, month by disappointing month. Don’t volunteer to take on additional commitments with work or family while you are having IVF, or at least during the months you’ve got IVF scheduled. Keep up the planning ahead, so if it’s disturbed by a pregnancy – well, that’s life!
Remember, you’re not alone – 10 to 15% of couples take longer to achieve a pregnancy than they think it should. Sometimes when you share your diagnosis you find others in similar situations, and there’ll be couples who’ve been trying longer than you have. A good support group can help keep you grounded and centered.