Causes of Reduced Fertility (Subfertility)

There are many factors that contribute to a couple’s fertility; we aim to identify any problem areas for you so we can best focus your management to achieve a successful pregnancy.

Difficulty in getting pregnant is more common than you think, approximately 1 in 7 male-female couples seek medical advice due to difficulty conceiving a baby. It is important to consider the fertility of both the male and female, as problems with either can reduce the chance of conception, and fertility for both will reduce with older age. For this reason we like to see you as a couple during your consultations, as well as being able to offer any advice or counselling you may benefit from. We know that fertility problems and treatment can be emotionally and physically draining, and can affect your relationship by changing your attitude towards sex, so counselling or support groups can be very helpful and should not be something that is avoided or seen negatively.

The good news is that up to 80% of couples where the female is under 40 years old and who are having regular unprotected sexual intercourse (2 to 3 times a week is recommended) will become pregnant within a year of trying! Of those who do not conceive within the first year, around half will conceive within the second year. So the odds are in your favour!

Here is a list of general health issues that can affect fertility and how to minimise them:

• Being overweight or underweight – aim for a healthy weight with a BMI value of 19-30, in women this can also help to regulate your periods, and group diet and exercise programmes can help

• Smoking tobacco or marijuana – active and passive smoking reduces fertility in women and the quality of semen in men; stopping smoking programmes and nicotine replacement can improve fertility as well as your general health

• Excessive alcohol consumption – avoiding alcohol is the healthiest option but limiting alcohol intake to 1-2 units/week for females and 3-4 units/week for males is also helpful for fertility, the most important thing is not to binge drink as this can affect a growing baby and reduce sperm quality

• Excessive physical or emotional stress – this journey can be stressful enough, try to avoid other sources of stress such as deteriorating health (keep any other medical conditions well managed) and physically-draining workloads (could include reducing long shifts or avoiding more physical tasks) 

• Body exposure – environmental toxins such as lead or pesticides can affect fertility, as can exposure to radiation (so inform staff that you are trying to conceive prior to having any hospital scans or radiotherapy treatment to see if alternative options are available)

• Medications – some medicines can affect fertility so it is best to speak to your healthcare provider (either GP or fertility specialist) when you start trying to conceive to see if any other medicine options would be better for you

• General advice: regular unprotected sexual intercourse (every 2-3 days), females should take folic acid supplements to reduce risks to the baby if you are successful, men should avoid excessive heat and tight-fitting underwear as this can affect sperm quality  

Unfortunately, some couples may have problems that prevent pregnancy, and this is where we come in. Both males and females can have fertility issues, and identifying where the issue lies is the first step in your conception journey. From here, we can increase your chances of conceiving through general health advice, specific investigations and treatments, or assisted conception as a last resort. The conditions below are grouped into problems with ovulation, transport of the egg through the fallopian tube, implantation into the uterus/womb, sperm quality, and unexplained subfertility.

Ovulation Problems

 Polycystic Ovary Syndrome (PCOS)

• Has no known cause but can run in families
• Due to altered levels of hormones including testosterone
• Symptoms (ranging from mild to severe) include having irregular or no periods, difficulty getting pregnant, increased facial and body hair, loss of hair on the head, difficulty losing weight, skin problems, mood changed such as depression
• Diagnosed based on criteria: symptoms/altered hormone levels, having irregular or no periods, and appearance of ovaries on ultrasound scan
• You can develop resistance to insulin which helps to regulate blood sugar; the diabetes medication Metformin can sometimes help with symptoms of PCOS for this reason
• Management is symptom-based as there is no cure, and trying to reduce long-term health risks
• Oral contraceptive pills can help with symptoms if you are not trying to get pregnant
• Weight loss can help restore normal hormone balance and so improves symptoms
• Body hair can be targeted with shaving, waxing, epilating, creams and electrolysis or laser treatment
• To regulate ovulation and help with getting pregnant we can use medication (see Clomid and Letrozole below) and/or a surgical procedure to stimulate the ovaries to release an egg
• If your periods are occurring less than 3 times a year we can use progesterone tablets to induce a period to protect the lining of the womb
• PCOS can increase your risk of diabetes and heart disease so having a healthy lifestyle and monitoring any symptoms by having regular check-ups at the GP will help to prevent these

 Premature Ovarian Insufficiency

• Also known as premature ovarian failure
• Diagnosed when the activity of the ovaries decreases before the ‘normal’ age of menopause
• Ovarian activity includes release of oestrogen to control menstrual cycles, so when oestrogen release decreases your periods will slow down and eventually stop
• Average age for menopause in the UK is 51
• Early menopause can be due to certain medications or treatments such as chemotherapy
• Premature ovarian failure/insufficiency is when the eggs within the ovaries (you are born with all your eggs) run out, or the ovaries stop producing oestrogen so eggs are not released
• Symptoms are the same as those of menopause: reduced/no periods, hot flushes, night sweats, mood swings, vaginal dryness
• Diagnosis is via blood tests for the hormones involved in regulating the ovaries (oestrogen and follicle stimulating hormone)
• There is no cure for premature ovarian failure/insufficiency but Hormone Replacement Therapy (HRT) can help with symptoms
• If your ovaries are not releasing eggs there is very little chance of a natural conception, you would likely be offered assisted conception using donor eggs or your own eggs if they have been stored in the past

 Other Hormonal Conditions

Hormones in the body talk to each other to keep the body systems regulated. Changes in the levels or activity of some hormones can affect the activity of the ovaries and regulation of menstrual cycle. Specific examples include hormones released by glands such as the hypothalamus, pituitary gland and the thyroid gland. There are many conditions associated with these glands including overactive or underactive thyroid, pituitary tumours and genetic disorders causing dysfunction of the hypothalamus. If you are known to have a condition affecting these glands you should discuss your fertility with a specialist for that condition. 

Obstruction of Fallopian Tubes

 Endometriosis

• A long term condition where tissue that normally lines the inside of the uterus/womb (endometrial tissue) is present outside the uterus
• The cause is unknown but there are theories being investigated
• Endometrial tissue can be present on the ovaries (where it can form cysts), on the fallopian tubes or surface of the uterus, or on the wall of the abdomen and pelvis causing pain during sex
• There is no cure but depending on the severity there are medications and surgery that may help
• Endometriosis can affect fertility depending on severity and location; cysts on the ovary may prevent egg release, and tissue on the fallopian tubes can make them stick to the surrounding tissues causing them to form ‘kinks’ and preventing eggs getting to the uterus
• Natural conception is usually still possible
• The main symptom is pain:
  • Intense pain mostly during your period
  • Pain when opening bowels
  • Pain during sexual intercourse
  • Milder pain at other times of the month
• It can also affect your mood and cause sleep disturbances
• Medical treatments interfere with the menstrual cycle to stop the release of eggs and stopping periods to help the pain – you would not be able to conceive on these medications
• Surgical management involves a keyhole surgery to remove the endometrial tissue within your pelvis – this should not affect fertility but can cause scar tissue which may ‘kink’ the fallopian tubes
• If you have endometriosis and fall pregnant you should monitor closely for pain and bleeding as a pregnancy within a ‘kinked’ tube may be an ectopic pregnancy (pregnancy outside the womb) and would require treatment – ectopic pregnancies cannot survive and can be life-threatening to the mother 

Pelvic Inflammatory Disease (PID) and STIs

• Inflammation of the female upper genital tract (uterus, fallopian tubes and ovaries)
• Caused by infection, usually bacteria that have travelled up from the vagina
• Common causes include chlamydia and gonorrhoea, but there are others
• Can be due to overgrowth of normal bacteria that live in the vagina (normally healthy)
• Symptoms include
  • Lower abdominal pain
  • Pain or discomfort during sex
  • Periods that become more heavy or painful
  • Pain when passing urine
  • Bleeding between periods or after sex
  • Vaginal discharge that can be yellow/green and smelly
  • If not treated you may become severely unwell with severe pain, fevers and vomiting
• PID can be treated with antibiotics by mouth or through a drip depending on severity
• If antibiotics do not clear the infection you may require keyhole surgery to wash out the infection
• Inflammation of the fallopian tubes can cause scar tissue to form which can make them ‘kinked’ or stick to other tissues which increases the risk of an ectopic pregnancy
• Severe scarring may block the tube completely but most women who are treated early can still have a natural conception

Scar Tissue and Peritoneal Adhesions

• Adhesions (similar to scar tissue) form between structures and stick them together
• They can be caused by any infective or inflammatory process as part of natural healing, including pelvic infections (PID), inflammation in the abdomen (appendicitis), and after a surgical procedure
• They can form between the reproductive organs (uterus, fallopian tubes, ovaries) and other structures in the pelvis (small bowel, abdominal wall)
• Adhesions can cause changes in the shape and position of the reproductive organs which can interrupt the process of conception
• Adhesions can be removed during surgery, but the surgery itself is likely to cause new adhesions, so we do not do surgery just to treat them

Abnormalities of the Uterus

Abnormal Uterine Development

• During development the uterus (womb) is formed by the joining of a left and right tube (Mullerian ducts) to form a single cavity
• The cause for these abnormalities is unknown
• A change in this process will produce a uterus that is not formed as normal
• Examples include a septate uterus (has a dividing septum within the uterine cavity), bicornuate uterus (heart-shaped uterus), and double uterus (each duct forms a separate uterus)
• Depending on the severity of the abnormal structure, a successful pregnancy may require a caesarean section (C-section) to safely deliver the baby

Uterine Fibroids and Polyps

• Benign (non-cancerous) growth of uterine tissues can reduce fertility by affecting the womb muscular layer (fibroids) or the womb lining (endometrial polyp)
• Fibroids can occur completely within the muscle layer, at the outer layer extending out into the pelvis, or at the inner layer extending into the cavity of the womb
• Only very large fibroids in the muscular layer or those extending into the cavity tend to affect fertility
• Similarly, endometrial polyps extending into the cavity can also affect fertility
• The size and location of polyps or fibroids may prevent the normal process of conception
• If the polyp or fibroid changes the shape of the cavity within the uterus it increases the risks of miscarriage and early labour
• Surgery can be an option to remove fibroids and polyps but is only necessary if very large, causes significant symptoms or would affect a pregnancy

Reduced Sperm Quality

Sperm quality is a collective measure of the number, motility and shape of the sperm. A problem which affects any of these will reduce the chance of a sperm successfully penetrating and fertilising an egg. Issues can arise from the production of the sperm or in the delivery mechanisms including transport from the testes to the penis or problems with ejaculation. Some of these factors are reversible while some are irreversible. Some important causes of reduced sperm quality are listed below.

•   Infection of the reproductive organs (epididymitis or orchitis) can cause organ scarring which interferes with sperm production and sperm health

•   Infection by STIs (chlamydia/gonorrhoea etc.) or HIV can cause permanent blockages due to scarring

•  Other infections such as mumps can cause scarring

•  Cancer and cancer treatments - includes cancers (or benign growths) of the reproductive organs (testicles, epididymis) or glands affecting the reproductive cycle (pituitary, hypothalamus); chemotherapy and radiotherapy to the reproductive organs can reduce sperm production  

•  Hormone imbalances of the reproductive and other related organs (hypothalamus, pituitary gland, thyroid, adrenal glands, testes) can alter sperm production and health

•  Varicocoele - a swelling of the vein which drains blood from the testicles, is usually reversible; can reduce sperm number, motility or shape

•  Undescended testicles - testicles fail to descend into the scrotum during development and may require surgery; usually affects sperm quality

•  Problems with ejaculation/sex - includes failure to ejaculate and retrograde ejaculation (semen flows backward into the bladder) as well as painful sex, may be reversible depending on the cause, causes include diabetes, spinal injuries, certain medications, surgery to the bladder/prostate/penis

•  Genetic conditions such as Kleinfelter's syndrome and Cystic Fibrosis can interfere with sperm production and delivery

•  Certain medications can affect sperm production (including testosterone replacement, long term steroids, arthritis drugs)

•  Avoidable factors: smokinglowers sperm count, smoking marijuanalowers sperm count and quality, alcoholabove the recommended limits can lower testosterone in the body causing decreased sperm production and erectile dysfunction, anabolic steroids used for muscle bulking can cause the testicles to shrink which reduces sperm production

Unexplained

Around 1 in 4 couples do not have any cause found for their difficulty conceiving; this is termed unexplained subfertility. This means there is nothing to focus treatment on, so the options are limited. If it has been over 2 years of regular unprotected sexual intercourse then you should be offered IVF (see below for more information on this, and eligibility criteria).