Dr Hemlata Thackare, Consultant Gynaecologist and Fertility Specialist London Women’s Clinic Wales & SW
Infertility is defined as the inability to get pregnant naturally despite having regular unprotected intercourse, after one year of trying. About one in seven couples have difficulty getting pregnant. Of these, one in three couples have problems due to female factors, a similar or slightly higher proportion are due to male factor, and the remaining are a combination of female and male factors. When infertility is due to female factors, it is termed as ‘female infertility’.
To achieve a pregnancy naturally, a woman needs to have regular periods, she must ovulate spontaneously in each cycle, she must have patent fallopian tubes and must have regular unprotected intercourse every two to three days. Her male partner must have a normal sperm count with good total and progressively motile sperm and normal morphology.
Age of the female partner is the single most important determinant of female fertility with pregnancy rates dropping off after 35 years with a more rapid decline after 40 years.
What basic fertility tests can I and my partner (male) have?
For women under 35 years of age, after trying for one year, you should have a blood test to check whether you are ovulating naturally. This test is typically carried out on cycle day 21 if you have a 28-day cycle, i.e. seven days post-ovulation and measure the level of the hormone Progesterone. If you have shorter or longer cycles, the test should be timed with the help of urinary ovulation tests which can detect the LH hormone surge. Discuss this with your GP when he/she orders the Progesterone test.
If cycles are irregular, your GP may also request blood tests to measure Prolactin, FSH, LH, Free androgen index and thyroid function tests. Your partner should have a semen analysis. This should be done after abstaining from intercourse for a maximum two to three days, if produced at home the sample must be collected in a special pot and delivered to the testing laboratory within 30 minutes.
Both partners must have chlamydia screening.
Women over 35 years old, those who have irregular cycles, have known gynaecological or other related problems should have basic fertility tests after trying for six months. Women over 40 years should have fertility tests as soon as they start trying.
What do we do if our basic fertility tests are normal?
Time is of the essence when you are dealing with infertility. Usually, 90% of couples where the female partner is under 40 years old will conceive naturally within two years of trying for a pregnancy.
You should be referred to a Fertility Specialist either in the NHS hospital or a specialist Fertility Clinic for further investigations. Some couples may simply need reassurance with some advice about lifestyle changes such as help to stop smoking or lose weight.
What tests will the Fertility Specialist advise?
The specialist will want to assess your ovarian pool of eggs, i.e. your egg reserve. This is commonly done by measuring the level of anti Mullerian hormone (AMH) in your blood.
The specialist will also advise an ultrasound scan of the pelvis to check the uterus and ovaries; this can be done externally via your tummy (transabdominal) or internally through the vagina (transvaginal). The transvaginal scan is more accurate. The scan will check on the shape and size of the uterus, the cavity of the womb and the lining of the womb. It will also check the ovaries for any abnormalities and count the number of follicles (tiny sacs in which the eggs develop).
You will also be advised a procedure commonly known as the Dye test to check patency of the two fallopian tubes. Fallopian tubes are important for picking up the ovulated egg from the ovary, for fertilisation of the egg with sperm and embryo development for the first three to four days after fertilisation. HyCoSy is an outpatient ultrasound procedure to assess tubal patency.
Your partner may be advised to repeat the semen analysis if the first sample does not meet the normal standards.
What are the common causes of Female Infertility?
The causes can be divided into Ovulatory problems, tubal problems, uterine problems or others such as Endometriosis. One in four couples have Unexplained Infertility.
Ovulatory problems can be due to Polycystic Ovarian Syndrome (PCOS), very high or very low BMI less than 19, high Prolactin level, excessive exercise, high mental or physical stress, premature Ovarian failure.
Tubal problems giving rise to blocked tubes can be due to sexually transmitted infections, most commonly Chlamydia, pelvic inflammatory disease, previous ectopic pregnancy, abdominal surgery or other infections such as Tuberculosis.
Uterine problems can be due to pelvic inflammatory disease, inflammation of womb lining, fibroids, polyps, scarring in uterine cavity either due to infection or surgical procedure, cervical mucus problems or scarring of the cervix.
Endometriosis is a condition wherein cells similar to those lining the womb develop outside the womb cavity on the pelvic wall, bowel, bladder or ovaries. Because these cells are responsive to hormonal changes that happen during a normal menstrual cycle, they bleed during a period and cause scarring as the blood gets absorbed. They
can form cysts in the ovaries called Endometriosis or Chocolate cysts which can affect female fertility.
Some patients have vaginismus causing difficulty having penetrative intercourse.
What are the treatments available for Female Infertility?
Treatment depends on the cause of the infertility and can range from medication to induce ovulation in case of ovulatory problems or IVF for tubal problems, endometriosis or unexplained infertility.
It is important that you proactively make appropriate changes to your lifestyle, stop smoking, reduce alcohol intake to no more than 2-3 units per week, achieve healthy BMI between 19 and 23 by a combination of healthy balanced diet and regular exercise, review medication with your GP/consultant to ensure it’s safe during pregnancy and take Folic acid and Vit D.