Infertility: the state of being unable to conceive.
Subfertility: the state of having difficulty with conception that requires some form of outside intervention.
Primary infertility: describes a couple who haven't conceived after two years of regular unprotected sex.
Secondary infertility: describes a couple who, after having one or more babies, are experiencing difficulties in conceiving or carrying further pregnancies full term.
Fertility problems affect about 15% of couples in the UK. The National Institute for Health and Clinical Excellence (NICE) states that couples who have not been able to get pregnant after 2 years of regular unprotected sexual intercourse are classified as having a fertility problem. However, most doctors currently offer couples initial tests after one year.
An averagely fertile couple in their mid twenties having regular sex have a 30% chance of conceiving in their first month of trying, and 90% of couples (of any age) who will ever conceive naturally will have done so within twelve months. About 10% - 15% of couples will still not have conceived, and will be able to get basic tests done on the NHS to see if there is an obvious cause to their problem.
Even after the most exhaustive tests, about 20% of infertile couples are labelled as having ‘unexplained infertility’ as no obvious cause can be identified.
About 30% of the couples experiencing difficulties conceiving will have a male factor as the cause of the problem. Nowadays, sperm analysis enables us to pinpoint exactly what the problem is.
• Low sperm count: healthy men produce at least 20 million sperm per millilitre of ejaculate, and anything below 10 million is deemed too low
• No sperm count: non-production of sperm can be a result of childhood infection or a physical obstruction between the testicles and penis
• Poor sperm motility: at least 50% of sperm need to have A or B motility grades; anything less and the sperm may not be able to swim through the cervix to reach the fallopian tube where the egg is waiting
• Poor sperm morphology: abnormally shaped sperm are not able to penetrate the outer layer of the egg and may contain genetic defects. At least 50% of sperm must be living, with at least 14% having perfect morphology
• Retrograde ejaculation: mechanical problems may prevent the sperm from ever leaving the penis, typically being deviated into the bladder
• Erectile dysfunction: the inability to maintain a stiff enough erection may prevent the sperm being delivered to the cervix
There is no simple drug treatment to increase sperm count or correct morphology. Couples undergoing ART where male infertility are usually offered either Intrauterine Insertion (IUI) or Intracytoplasmic Sperm Injection (ICSI).
Assisted Reproductive Treatment (ART)
ART ranges from simple interventions such as fertility drugs with accurately timed intercourse to different forms of artificial insemination.
• Ovulation Induction: this involves stimulation of the ovaries by chemical means and is used in cases such as polcystic ovarian syndrome (PCOS) where ovulation is erratic or non-existent
• Intrauterine Insertion (IUI): couples with mild male problems or unexplained infertility are typically offered this technique which involves washing and preparing a sperm sample and delivering it into the uterus by a fine catheter at the time of ovulation. Ovarian stimulating drugs may or may not be used in the woman
• In Vitro Fertilisation (IVF): the most common for of ART, IVF uses drugs to stimulate egg production in the ovaries, removes them and introduces them to sperm outside of the body. After three or five days, two fertilized eggs are replaced into the uterus, with any spare fertilized eggs of suitable quality being frozen for further attempts
• Gamete Intrafollopian Transfer (GIFT): in this technique eggs are removed from the ovaries and placed in the fallopian tubes with a prepared sample of sperm. A complex technique, GIFT is no longer widely practiced in the UK
• Intracytoplasmic Sperm Injection (ICSI): individual sperms are introduced into individual eggs; after three or five days, one or two fertilized eggs are placed in the uterus. Any spare fertilized eggs of suitable quality are frozen for further attempts. ICSI is typically used where the sperm count, motility or morphology is poor
The average success rate for IVF treatment using fresh eggs in the UK is
• 28.2% for women under 35
• 23.6% for women aged 35-37
• 18.3% for women aged 38-39
• 10.6% for women aged 40-42
There are no official government compiled statistics for IVF above the age of 42, but different sources suggest a success rate of 1-4%.
Risks of ART
Drugs that stimulate the ovaries can have unwanted side effects. When used in cases of polycystic ovaries, gonadotropin drugs can result in an increase in the number of cysts.
Stimulation of the ovaries can make them over respond, producing a condition known as Ovarian Hyperstimulation Syndrome (OHSS) . Symptoms of OHSS can be as mild as mild abdominal bloating and pain or as severe as acute respiratory distress, thromboembolism, urinary and renal complications.
A successful pregnancy cannot be guaranteed by ART, with success rates being well below 50%. Most couples – especially the woman – will experience an emotional roller coaster as she goes through the changing drug regime and has to cope with possible failure at every stage.
ancient China to modern England.