Infertility is the inability of a couple to conceive a child. We speak of infertility when a couple who have frequent sexual relations and who do not use contraception do not succeed in procreating for at least a year (or six months when the woman is over 35 years old).

For a woman to get pregnant, a chain of events is necessary. Her body, and more specifically her ovaries, must first produce a cell, the oocyte, which travels to the uterus. There, in the presence of sperm, fertilization can occur. Sperm can survive 72 hours in the female reproductive system and the egg must be fertilized within 24 hours of ovulation. When these two cells merge, an egg is formed and then implanted in the uterus, where it will be able to develop.

Infertility can be very difficult for couples who want to become parents but are unable to do so. This incapacity can have significant psychological repercussions. However, there are many treatments for infertility that can greatly increase a couple’s chances of becoming parents.

Difference between infertility and sterility

Sterility is the inability of an individual or a couple to naturally conceive a child while infertility, on the other hand, refers to the inability to have children after 1 year of regular sex without contraception.

Concretely, we go from infertility to sterility when the chances of obtaining a pregnancy fall to 0. In this case, there is a total impossibility of obtaining a spontaneous pregnancy. For someone deemed sterile, it is necessary to turn to medically assisted procreation treatments or procedures.

Prevalence of infertility

Infertility is very common since it affects between 10% to 15% of couples. The American Centers for Disease Control and Prevention (CDC) confirms that nearly 1 in 10 women would have difficulty getting pregnant. 80 to 90% of women get pregnant within 1 year and 95% within 2 years.

In Canada, according to the Canadian Infertility Awareness Association (ACSI), nearly 1 in 6 couples will fail to conceive within the first year of stopping all contraception.

In France, according to the 2003 national perinatal survey and the 2007-2008 epidemiological observatory for fertility, nearly 1 in 5 couples would be affected by infertility after 12 months without contraception. According to the survey, 26% of women became pregnant from the 1st month without contraception and 32% more than 6 months later (including 18% after 12 months and 8% after 24 months).

According to the World Health Organization (WHO), between 48 couples and 186 million individuals suffer from infertility globally.

Although data are lacking, it seems that more and more women are having difficulty getting pregnant and are also taking longer. Environmental or infectious factors could be responsible for this evolution. Being overweight is also singled out. You should also know that fertility decreases with age. However, women are expecting their first child later and later, which could also explain why infertility problems are more and more frequent.

The causes of infertility

The causes of infertility are very varied and can affect men, women, or both partners. In a third of cases, infertility affects men only, in another third it affects only women and finally, in the remaining third, it affects both.

In men

Male infertility is mainly due to too little production (oligospermia) or a complete absence (azoospermia) of sperm in semen. Azoospermia may be due to a lack of production in the testes or a blockage of the ducts that allow sperm to migrate. Sperm may also be malformed (teratospermia) or immobile (Asthenozoospermia). The sperm can then no longer reach the oocyte and enter it.

Male infertility can also be caused by premature ejaculation problems. In this case, the male ejaculates at the slightest excitement, often even before penetrating his partner.

Dyspareunia (painful intercourse for women) can also prevent penetration.

In retrograde ejaculation, the semen is sent to the bladder and not to the outside. Certain environmental factors, such as exposure to pesticides or frequent excessive heat in saunas and hot tubs, can decrease fertility by affecting sperm production.

More general disorders such as obesity, excessive consumption of alcohol or tobacco also limit male fertility.

Finally, certain anticancer treatments such as chemotherapy and radiotherapy sometimes limit the production of sperm.

In women

The causes of infertility in women are again multiple. Some women may suffer from ovulation abnormalities. Ovulation may be nonexistent (anovulation) or of poor quality. With these abnormalities, no oocyte is produced and therefore fertilization cannot take place.

The fallopian tubes, which are located between the ovaries and the uterus and allow the embryo to migrate to the uterine cavity, may be blocked (for example, with salpingitis, inflammation of the tubes, or adhesion problem following surgery).

Female infertility may also be caused by endometriosis, uterine fibroid, or polycystic ovary syndrome, which is a hormonal imbalance that causes cysts to appear on the ovaries and is manifested by irregular periods and sterility.

Medicines, such as cancer treatments, can cause infertility.

Thyroid problems, as well as hyperprolactinemia, can also be responsible. This increase in the level of prolactin, a hormone present during breastfeeding, can affect ovulation.

The diagnosis

In case of infertility, it is necessary to try to find its cause. The various tests offered can be long. The specialist usually starts by checking the couple’s general state of health, taking into account their sex life. In about a third of cases, the couple’s infertility remains unexplained.

The Huhner test is performed a few hours after intercourse. It checks the quality of cervical mucus, a substance produced by the uterus that allows sperm to move better and reach the uterus.

In men, a spermiogram is used to analyze the content of the sperm: the number of sperm, their mobility, its appearance, its abnormalities, etc. If abnormalities are detected, an ultrasound of the genitals or a karyotype may be requested. Doctors also check if ejaculation is normal. Hormonal tests, such as testing for testosterone, from a blood sample, are frequently performed.

In women, the proper functioning of the reproductive organs is checked. The doctor also makes sure that the menstrual cycle is normal. Blood tests to check the amount of hormones present can help make sure the woman is ovulating.

A hysterosalpingogram helps to visualize the uterine cavity and the fallopian tubes. This examination allows, thanks to the injection of a contrast product, to detect any blockage in the tubes. Laparoscopy, an operation that visualizes the inside of the abdomen and therefore the ovaries, fallopian tubes, and uterus, may be prescribed if infertility is suspected. It can help detect endometriosis. A pelvic ultrasound can also detect abnormalities of the uterus, tubes, or ovaries. Genetic tests may be necessary in order to detect a genetic origin of infertility.

Symptoms of infertility

The main sign of infertility is a long delay in getting pregnant despite actively trying. This is why an infertility assessment is recommended after 12 months of unsuccessful trials or after 6 months in women over 35 years old.

Depending on the cause of infertility, other symptoms can also raise the alarm, such as erectile dysfunction, very irregular menstrual cycles, or pelvic pain.

Irregular and heavy periods

The type of menstruation experienced by women can be a sign of infertility. The onset of painful periods can be a sign of endometriosis. Endometriosis is a condition that affects the ovarian reserve and which, in severe cases, changes the pelvic anatomy, making pregnancy difficult.

Having a painful and heavy period can be a sign of the existence of benign tumors in the lining of the uterus: these are called uterine myomas. If they are found in the endometrial cavity (submucosal myomas), they can make it difficult to conceive.

The presence of irregular menstrual cycles, especially if they are very long – those considered regular last 25 to 35 days, with an average of 28 days – may be a sign of polycystic ovary syndrome. This disorder is a hormonal alteration that prevents ovulation and therefore pregnancy. This can also occur with acne and hirsutism (excessive growth of hair in certain parts of the body).

Amenorrhea or lack of menstruation also prevents pregnancy. This is often due to menopause, but sometimes it is caused by hormonal changes that can be corrected with adequate medical treatment. This is the case with low-weight women or those with thyroid dysfunction.

Age, a key factor

Although a woman’s age is not in itself a sign of infertility, it should be remembered that fertility declines considerably with the passing years. The ovarian reserve — the number of eggs a woman has at birth — decreases over time. Indeed, by the age of 35, the possibilities of becoming pregnant begin to decline seriously. Therefore, we need to be very attentive to these signs if they appear from this age.

On the other hand, if there has been a previous episode of pelvic inflammatory disease or salpingitis (infection and inflammation of the fallopian tubes) there may be tubal adhesions and obstructions. If both tubes are blocked, natural fertilization will not be possible and in vitro fertilization will have to be used.

Varicocele

In men, it is more difficult to appreciate the indirect signs of a possible problem of low fertility. However, it should be noted that the visible presence of dilated veins around the testicular bursa – known as varicocele – can interfere with proper sperm production. On the other hand, having a history of cryptorchidism – a testicle not descended at birth and corrected late – may also be related to poorer sperm quality and therefore, greater difficulty producing.

Retrograde ejaculation

When a man suffers from retrograde ejaculation, the sperm takes the wrong direction during ejaculation and ends up in the bladder instead of being expelled through the urethra. Retrograde ejaculation is a defect in the valves that regulate the flow of urine relative to that of semen in the urethra; this rare disease is sometimes the consequence of diabetes and infertility.

Risk factors

There are different risk factors for infertility such as:

• Age. In women, fertility decreases from the age of 30. This can be explained by the fact that the eggs produced at this age more frequently have genetic abnormalities. Men over the age of 40 can also have reduced fertility.
• The tobacco. Smoking reduces a couple’s chances of conceiving a child. Miscarriages are also believed to be more frequent in smokers.
• Alcohol.
• Excessive consumption of caffeine.
• Overweight or obesity.
• Excessive thinness. Suffering from eating disorders such as anorexia for example can interfere with a woman’s menstrual cycle and thus reduce her fertility.
• Heavy physical activity can disrupt ovulation.

Prevention of infertility

It is difficult to prevent infertility. However, adopting a healthy lifestyle (avoiding excessive alcohol or coffee consumption, not smoking, not being overweight, practicing reasonable physical activity regularly, etc.) can contribute to improving the fertility of men and women and therefore of the couple.

The optimal frequency of intercourse to conceive a child would be between 2 and 3 times per week. Too frequent sex could deteriorate the quality of semen.

A more moderate intake of trans fatty acids could also affect fertility. Excessive consumption of these fats would increase the risk of infertility in women.

Treatment of infertility

The treatments offered obviously depend on the causes of infertility found during diagnosis. They also adapt to the couple’s age, medical history, and the number of years they have suffered from infertility. Despite the variety of treatments available, some causes of infertility cannot be corrected.

In men, drugs or behavioral therapy can treat certain ejaculation disorders and allow a couple to conceive a child. If there is an insufficient number of sperm in the semen, hormones may be prescribed to correct this problem or surgery may sometimes be offered (to correct a varicocele, a dilation of the veins of the spermatic cord, located in the testes, for example).

In women, hormonal treatments for menstrual cycle problems can be effective. Treatments like clomiphene citrate (Clomid, by mouth) are prescribed to stimulate ovulation. This medicine is effective in cases of hormonal imbalance because it acts on the pituitary gland, a gland that secretes the hormones that trigger ovulation. Several other hormones can be prescribed by injection to stimulate ovulation. In the case of hyperprolactinemia, bromocriptine may also be prescribed.

In some cases, surgery may be necessary. If the fallopian tubes are blocked, the doctor will most likely recommend surgery. In endometriosis, drugs to stimulate ovulation or in vitro fertilization may be necessary to hope to conceive a child.

Medically assisted procreation techniques are sometimes necessary in cases of infertility. In vitro fertilization is the most frequently used assisted reproduction technique. The man’s sperm is placed in the presence of the woman’s egg in the laboratory, then the embryo is re-implanted in the uterus of the future mother.

Psychological effects of infertility

Infertility often causes great psychological stress for affected couples. Unwanted childlessness often pushes a couple into an emotional crisis, wrapped in feelings such as anger, sadness, self-reproach, or impotence. Changes can also occur in social contact with family or friends, such as withdrawing or avoiding joint activities with pregnant women or a couple with children. In addition, the partnership is heavily burdened by an unfulfilled desire to have children — therefore, mutual understanding and open debate between the partners are of great importance.

If a couple has opted for medical treatment, the depression is often followed by increased euphoria. During the waiting time between the individual treatment steps, the psychological pressure can increase even further. Therefore, depressive episodes are not uncommon in the therapy phase. The enormous burdens and risks of fertility treatment are often underestimated.

Often the partners deal differently with the unwanted childlessness, leading to tensions within the couple’s relationship. Sexuality and the actual togetherness often fade into the background. If no physical causes are found, the couple can become even more concerned with the question of why and the increasing pressure for success can prevent the very goal they are trying to achieve. A couple should therefore not be afraid to seek professional assistance or psychological counseling during treatment or in advance.

In conclusion

Infertility issues are delicate issues for couples. Do not hesitate to talk to your doctor or gynecologist. The first step is to fully investigate the causes of this infertility in both partners. After the cause is well established, relatively simple procedures can be proposed and are often effective.

If these procedures are ineffective, IVF may be considered. However, you should know that the stages of in vitro fertilization are long, invasive, and very expensive.