Family doctor

What is infertility?

A typical fertile couple in their mid-to-late 20's, having regular sex, has about a 20-25% chance of conceiving each month. After 6 months, at least three quarters of young fertile couples will be pregnant, and after a year at least 90%. Infertility is usually defined as not being pregnant after a year of trying, but some couples know or suspect they are infertile well before a year is up. For instance, the woman might have irregular periods or not ovulate at all.

Studies from various European countries show 15-20% of couples experience infertility some time in their reproductive life, so it is a very common problem. For many people infertility is not absolute. The chance of conception may be only 5% a month instead of 20%, so it takes longer to get pregnant.

For some people infertility is absolute - there may be no sperm, or the woman's fallopian tubes may be blocked. This used to be called sterility, but this is a misleading term because modern treatment gives most 'sterile' couples a good chance of having a child. Very broadly, about half of infertility is male based and about half female based. Whatever, it is a couple's problem and requires the couple to work together towards a solution.

When should I do something?

The right time to seek help is when you are concerned about your fertility. Often, simple tests that check ovulation and sperm quality can provide reassurance to a couple so that they are happy to try a little longer before more intensive investigation. On the other hand, these simple tests can often identify a severe problem quickly. A woman's fecundability (the chance of conceiving each month) falls with age, especially in the late 30s and early 40s, so age is also a factor to consider. Generally, the older the woman the faster she should seek help. If there is a lesson to be learnt from the past, it is not to take too long to seek advice and help.

What happens when I see a fertility specialist?

One of the first jobs your fertility specialist has to do is to estimate your chance of a spontaneous pregnancy (without medical intervention) in the next 1 to 3 years. The first step is to investigate possible causes of infertility. The common tests are:

• Medical history of both partners
• Semen analysis for the man, to look at the number of sperm ('concentration'), the proportion of sperm moving and the way they move ('motility'), and the shape of the sperm ('morphology')
• Ovulation tests, usually blood tests for progesterone timed 6-8 days before next menstrual period.
• Laparoscopy, a simple operation in which a type of telescope is inserted into the belly to look at the woman's fallopian tubes. Often dye is passed through the Fallopian tubes at the same time, and the uterus and even the tubes themselves can be viewed from within using a hysteroscope and a falloposcope.

Some times major factors are discovered - few or poor quality sperm, extensive scarring in or around the fallopian tubes, or irregular ovulation. The chance of spontaneous pregnancy is very low, and the treatment options are clear. Quite commonly, the factors are less severe - sperm quality less than average, some endometriosis (where cells that usually line the uterus grown in the belly), or a combination of mild factors. In around 20% of couples everything looks 'normal', which is described as 'unexplained infertility'. In these cases, the duration of infertility seems to be the most important predictor of the chance of spontaneous pregnancy in the future. The treatment options are often the same as for severe infertility, the question is when to try them. You and your specialist will need to map out a management plan - balancing the emotional, physical and financial 'costs' of possible treatments with the chance of success.