Infertility

Infertility is a disease of the male or female reproductive system that affects the body's ability to reproduce. It is the inability to achieve pregnancy after one year of regular, unprotected intercourse. For women over 35, this period is reduced to six months. According to the WHO, infertility affects one in six people of reproductive age globally. Although often seen as a woman's issue, it can involve either or both partners.

What Is Infertility?

Infertility occurs when a couple cannot conceive after a year of regular, unprotected intercourse. For women over 35, this period is shortened to six months. It can result from issues in the male or female reproductive systems or both. In about half of infertile couples, the male partner is solely or partly responsible. Infertility affects emotional and psychological well-being and should be recognised as a medical condition that often requires treatment.

WHO (2024) classifies infertility into two main types:

• Primary Infertility: Primary infertility occurs when a person has never achieved a pregnancy despite trying for at least a year.
• Secondary Infertility: Secondary infertility refers to difficulty conceiving again after previously achieving at least one pregnancy.

Some other types of infertility include:

• Male Infertility: Male infertility can result from issues like semen ejaculation problems, low sperm count, or abnormal sperm shape and movement.
• Female Infertility: Female infertility may stem from abnormalities in the ovaries, uterus, fallopian tubes, or endocrine system.
• Unexplained Infertility: In some cases, no specific cause is found, leading to a diagnosis of unexplained infertility.

Infertility can be a challenging issue for many couples, and identifying the early signs is crucial for timely intervention. 

• Menstrual Irregularities: Changes in the menstrual cycle, such as irregular periods or missed periods, can indicate fertility problems in women.
• Hormonal Imbalances: Hormonal issues like severe acne, hair loss, or weight gain may signal fertility-related conditions like polycystic ovary syndrome (PCOS).
• Painful Symptoms: Severe pelvic pain, cramping, and pain during intercourse may suggest endometriosis, affecting a woman's fertility.
• Male Sexual Dysfunction: Low sex drive, erectile dysfunction, and ejaculation difficulties can signal hormonal imbalances or fertility issues in men.
• Testicular Abnormalities: Testicular pain, swelling, or abnormalities may impact sperm production and male fertility.
• Hormonal Symptoms in Men: Hormonal imbalances can cause breast growth, reduced facial/body hair, and smaller testicles, which can affect male fertility.

Recognising these early signs and seeking medical advice can help couples address potential infertility causes and explore appropriate treatment options.

The primary symptom of infertility is the inability to conceive after one year of unprotected intercourse for couples under 35 and after six months for those over 35. However, other symptoms can vary depending on the underlying cause. 

• Menstrual Irregularities: Women may experience irregular cycles, ovulation problems, heavy periods, or skipped periods.
• Pelvic Pain and Bleeding: Pelvic pain, unpredictable vaginal bleeding, and heavy periods can be symptoms of fertility issues in women.
• Hormonal Imbalances in Women: Symptoms like skin changes, hair loss, excessive hair growth, and weight gain may indicate hormonal issues.
• Sexual Dysfunction in Men: Men may experience changes in sexual desire, hair growth, or erectile function.
• Testicular Symptoms: Men may notice testicular pain, swelling, lumps, or issues with ejaculation.

It's important to note that these symptoms can be associated with various health conditions. Hence, consulting a doctor is essential for accurate diagnosis and appropriate infertility treatment.

Infertility can stem from a variety of factors affecting both women and men, including:

• Ovulation Disorders: For women, ovulation disorders like PCOS are common causes of infertility. These conditions can disrupt the regular release of eggs from the ovaries, making conception difficult.
• Endometriosis: It is a condition where tissue similar to the uterine lining grows outside the uterus. This can cause scarring and blockages in the fallopian tubes, hindering fertilisation.
• Uterine Fibroids and Polyps: These growths can interfere with implantation, affecting a woman's ability to sustain pregnancy.
• Age: Age plays a significant role, as a woman's fertility declines with age due to a decrease in egg quantity and quality.
• Low Sperm Quality: For men, low sperm count, poor sperm motility, and abnormal sperm shape can contribute to infertility.
• Varicoceles: Enlarged veins in the scrotum can impair sperm production and quality.
• Hormonal Imbalances in Men: Low testosterone or hormonal problems can disrupt sperm production and sexual function.
• Genetic, Medications, and Environmental Factors: Male fertility may be affected by genetic factors, medications, or exposure to environmental toxins.
• Lifestyle Factors: Obesity, smoking, excessive alcohol use, and pollutants can negatively impact fertility in both sexes.

Understanding the underlying causes of infertility is crucial for developing targeted infertility prevention strategies and exploring suitable treatment options.

Infertility can be influenced by a variety of factors affecting both men and women. Some of them include:

• Age: For women, fertility declines notably after the mid-30s due to a decrease in egg quality and quantity (Sebastian-Leon et al., 2025). For men, while the decline in fertility with age is less dramatic than in women, it still occurs, especially after age 40.
• Certain Medical Conditions: Ovulation disorders such as polycystic ovary syndrome (PCOS), hyperprolactinemia, and thyroid issues can interfere with ovulation. Endometriosis, uterine fibroids, and other uterine abnormalities can also impact fertility.
• Chronic Diseases: Chronic diseases like diabetes, hypertension, and autoimmune conditions can impact fertility.
• Stress: Excessive or insufficient exercise, as well as extreme stress, can disrupt ovulation. 
• STIs: Sexually transmitted infections (STIs), such as chlamydia, and pelvic surgery can cause scarring and damage to reproductive organs.
• Hormonal Disorders: Hormonal disorders involving the hypothalamus or pituitary glands, such as high prolactin levels, can affect sperm production.
• Genetic Conditions: Genetic and congenital conditions like undescended testicles, mumps after puberty, and certain genetic disorders can impact male fertility.
• Environmental and Medical Factors: Environmental toxins, smoking, excessive alcohol use, and medical treatments like chemotherapy and radiation therapy can all impair sperm quality and quantity.

Understanding these risk factors is crucial for preventing and addressing infertility.

Infertility can lead to a range of emotional, psychological, and physical complications for both individuals and couples.

• Emotional Impact: The emotional toll of infertility can be significant, with many experiencing feelings of sadness, anxiety, stress, and hopelessness. The pressure to conceive can strain relationships, leading to communication difficulties and even the breakdown of partnerships.

• Social Isolation: Infertility can lead to social isolation, as individuals may feel uncomfortable discussing their struggles with family and friends. They may also avoid participating in social events that revolve around children.

• Physical Complications: In some cases, infertility can have physical complications, particularly for women undergoing fertility treatments. Ovarian hyperstimulation syndrome (OHSS) is a potential complication of in vitro fertilisation (IVF). This can cause abdominal pain, bloating, and, in severe cases, blood clots and kidney failure.

• Risks of Multiple Pregnancies: Fertility treatments increase the likelihood of multiple pregnancies, raising the risks of premature birth and low birth weight.

• Financial Strain: The high cost of infertility treatments adds significant financial stress to individuals and couples.

Recognising and addressing these potential complications is crucial for maintaining the overall well-being of those struggling with infertility.

While not all causes of infertility can be prevented, there are steps individuals can take to protect their fertility:

• Maintain a healthy weight by following a balanced diet and engaging in regular exercise.
• Avoid smoking and excessive alcohol consumption.
• Manage chronic health conditions, such as diabetes and hypertension.
• Reduce exposure to environmental toxins and hazards.
• Practice safe sex to prevent sexually transmitted infections.
• For women, track your menstrual cycle and ovulation to identify any irregularities.
• Consider fertility preservation options like egg or sperm freezing if delaying parenthood.
• Treat any known reproductive health issues promptly.
• Manage stress through relaxation techniques, counselling, or support groups.
• For men, avoid tight-fitting clothing and hot environments that can affect sperm quality.

By making lifestyle changes and being proactive about reproductive health, individuals can take steps to prevent infertility and increase their chances of conceiving.

Diagnosing infertility typically involves a comprehensive evaluation of both partners to identify potential causes and develop an appropriate treatment plan. 

• Physical Examination: The process begins with reviewing medical history, menstrual cycles, pregnancies, and lifestyle factors that may affect fertility.
• Ovulation and Hormonal Testing for Women: Tests assess ovulation and reproductive hormones, such as FSH, LH, and progesterone, to evaluate fertility status.
• Imaging Tests: Ultrasound and hysterosalpingography (HSG) help identify abnormalities or blockages in the uterus and fallopian tubes.
• Laparoscopy: This minimally invasive surgery diagnoses conditions like endometriosis or pelvic adhesions affecting fertility.
• Semen Analysis: Semen analysis checks sperm count, motility, and morphology as key factors in male fertility.
• Additional Tests for Men: Hormonal tests, genetic testing, and imaging may diagnose structural issues; a testicular biopsy might assess low sperm production.

Once the cause of infertility has been identified, healthcare providers can develop a personalised treatment plan to help couples achieve their goal of starting a family.

The treatment of infertility is highly personalised, based on the cause, age of the individual, duration of infertility, and reproductive goals. The infertility treatment combines medication, hormone therapies, assisted reproductive technologies, and surgical interventions to improve fertility outcomes in both men and women.

1. Hormonal cycle regulation (pre-treatment phase)

Short-term use of contraceptives may be recommended to regulate cycles before initiating fertility treatment or to manage underlying hormonal imbalances.

Commonly used agents include:

• Desogestrel: It helps regulate ovulation and control hormone levels in pre-treatment cycles.
• Etonogestrel: It supports ovarian suppression and helps prevent cyst formation.
• Levonorgestrel: It is used in hormonal therapy to stabilise the endometrial lining ahead of conception attempts.

2. Selective Estrogen Receptor Modulators (SERMs)

SERMs are frequently used to induce ovulation in women who do not ovulate regularly by increasing the body’s release of follicle-stimulating hormone (FSH).

• Clomiphene: It stimulates the ovaries to release eggs, and is widely used as a first-line ovulation induction medicine.
• Ormeloxifene: It is sometimes used off-label to balance hormone levels and assist in ovulation timing.

3. Synthetic Estrogen Hormone

Synthetic estrogens are used to support the endometrium and balance hormones during fertility protocols.

Example:

• Ethinyl estradiol: Promotes the growth of the uterine lining to ensure it is receptive for embryo implantation.

4. Progestins

Progestins help prepare the uterus for pregnancy and support the luteal phase (second half of the menstrual cycle), especially during fertility treatments or early pregnancy.

• Medroxyprogesterone: It supports hormonal balance and prepares the uterus for implantation.
• Hydroxyprogesterone: It is used in some instances to maintain progesterone levels.
• Dydrogesterone: It mimics natural progesterone and helps maintain early pregnancy.
• Dienogest: It is occasionally used to manage endometriosis-related infertility.
• Norethindrone: It regulates the cycle and supports the hormonal environment.
• Ulipristal acetate: Used in select cases, such as fibroid-related infertility, and only under medical supervision.

5. Intrauterine Insemination (IUI)

IUI is a simple, minimally invasive procedure where prepared sperm is placed directly into the uterus near ovulation.

• This method improves the chances of conception in couples with mild male factor infertility, cervical mucus issues, or unexplained infertility.

6. Surgery

Surgery may be necessary for women with uterine fibroids, endometrial polyps, or blocked fallopian tubes, and for men with varicocele. Although less commonly needed due to advances in non-invasive treatments, surgery can improve fertility outcomes when anatomical issues are present.

7. Assisted Reproductive Technology (ART)

Techniques like In Vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI) are often considered when other methods fail. IVF allows fertilisation outside the body, while ICSI involves injecting a single sperm directly into the egg, especially useful in cases of poor sperm quality or quantity. These procedures offer hope for many couples with complex fertility challenges.

Infertility can be a distressing issue for couples trying to conceive. It's important to know when to seek medical help. If you're under 35 and haven't conceived after a year, consult a fertility specialist. For women over 35, this timeline is reduced to six months as fertility declines more rapidly with age. Men should also seek medical advice if they have been unable to conceive with their partner after a year of trying.

However, there are certain situations where it's advisable to see a doctor sooner:

• If you have irregular or absent menstrual periods, known fertility issues, or have undergone cancer treatment, consult a fertility specialist. 
• If you have a history of pelvic inflammatory disease, endometriosis, or multiple miscarriages. 
• Men with low sperm count, testicular or prostate issues, or cancer treatment should also consult a doctor early. Early intervention can help identify the cause of infertility and improve the chances of successful treatment.

• Infertility affects millions of couples worldwide, with various causes, including ovulation disorders, male factor infertility, and anatomical issues.
• Symptoms of infertility include the inability to conceive after one year of regular, unprotected sexual intercourse (or six months for women over 35).
• Infertility can be caused by factors affecting both men and women, such as hormonal imbalances, reproductive disorders, and lifestyle factors.
• The management of infertility involves a range of treatments, including medications, intrauterine insemination, surgical procedures, and assisted reproductive technologies like IVF and ICSI.
• Medications used to treat infertility include clomiphene citrate, gonadotropins, metformin, letrozole, and antibiotics for male infertility.
• Couples who have been trying to conceive for a year or more should consider seeking medical advice from a fertility specialist.
• Prevention strategies for infertility include maintaining a healthy weight, avoiding smoking and excessive alcohol consumption, managing stress, and protecting against sexually transmitted infections (STIs).