intercourse.
Endometriosis can sometimes cause infertility. If you have severe endometriosis, with damage to the fallopian tubes or where your ovaries are trapped in adhesions preventing release of the egg, this obviously reduces your fertility. Doctors are uncertain whether mild endometriosis, where the tubes and ovaries remain normal, actually causes infertility. However, it is certainly more common in women with infertility. Indeed around 30 per cent of those with endometriosis have a fertility problem.
The lining of the womb
The fertilized egg implants into the lining of the womb. Doctors still do not fully understand just how this critical event occurs, but they do know that if the lining of the womb (the endometrium) is not ready for the fertilized egg, that implantation may fail. This lack of preparation might be due to insufficient progesterone, the hormone that prepares the lining of the womb for implantation, or it might be because the lining of the womb does not respond to the progesterone. This can be found in somewhere between 3 and 20 per cent of couples with a fertility problem. However, much of this information is not consistent and at present there is no good evidence that treatment can improve this. Furthermore, its role as a cause of infertility has been questioned. Doctors therefore do not routinely check the lining of the womb to evaluate its suitability for implantation.
Thickened or hostile mucous
Doctors know that some cases of infertility might be linked to ‘hostile’ cervical mucus, which the sperm finds difficult to penetrate and so cannot reach the womb. Many of the current treatments of fertility problems circumvent the sperm passing through the mucus by using assisted conception techniques.
The main fertility problems in men
• If a man does not produce enough sperm or the sperm are of poor quality, this can lead to difficulty in conceiving.
• There can sometimes be difficulty in the sperm travelling from the testicles down the fine tubes that carry the sperm to the penis.
Sometimes these tubes can be blocked and so, even though enough sperm is produced, it cannot reach the vagina or the fallopian tube to fertilize the egg that is waiting.
• Men who have an undescended testicle, which is often treated by surgery in childhood, may have a problem producing sufficient sperm, as can those who have surgery in the area of the testicle, including a hernia repair.
• The testicles are outside the body for a reason. Sperm production occurs best at a slightly lower temperature than your body. So there is a link between tight clothing and increased temperature of the scrotum that might impact on sperm production. Doctors are not certain whether wearing loose fitting underwear actually makes a difference and improves the quality of sperm, but it seems like a reasonable and simple thing to think about doing if you have a low sperm count.
• Sometimes, a viral infection like mumps when you are an adult can affect the testicles and lead to a problem in sperm production.
• Difficulties in sperm production can sometimes be caused by genetic problems.
• Certain medications for medical conditions can have an impact, too. In particular, both radiotherapy and chemotherapy for cancer treatment can cause difficulties with male fertility.
• Infections, including sexually transmitted infections, can cause scarring and blockage of the fine tubes that allow the sperm to travel from the testicles to the penis.
• Just as with women, if a man is overweight with a BMI over 29 his fertility can be impaired.
Seeking help
If you have been trying for a baby for more than a year, it is time to seek medical advice. Ideally, you and your partner should see the doctor together, rather than separately.
Consulting your doctor
The doctor will take a detailed history from you both, including your age, how long you have been trying to conceive, how often you have intercourse, previous contraception, whether you have any problems with intercourse, the presence of chronic medical conditions or long-term medication, and details of any previous pregnancies (including any pregnancies with previous partners and also any terminations of pregnancy).
You will be asked about menstrual problems and any history of pelvic infection or abdominal surgery. This is because infection or abdominal operations can lead to problems such as adhesions, which can cause the fallopian tubes to be blocked. Your partner will be asked about his occupation, any past medical problems, surgical operations or trauma to the testicles and any infections that can affect the genitals, such as mumps in adulthood. He will also be asked about any regular medication (as this can sometimes upset sperm function) and about any sexual difficulty such as premature ejaculation. The doctor will also want to know if either of you smoke and how much alcohol you drink. This is because smoking can reduce your fertility and excess alcohol consumption can upset sperm quality. You both may be examined.
Initial investigations
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Seeking help early
In some situations, you might want to seek an earlier assessment of your fertility. If, for example, there is a known factor that might affect fertility in you or your partner, such as an undescended testicle, cancer therapy, very irregular or absent periods, damage to the fallopian tubes from surgery or infection, or if the women is aged over 35 years.
Your doctor will tell you if there are any obvious problems and whether a specialist referral is required. Your doctor will give you some general advice, and point out the most important issues, such as the need to take folic acid, stop smoking, cut down or stop drinking alcohol, and you will be asked about your immunity to rubella and whether your cervical smear tests are up to date. You may also be checked for anaemia and hepatitis or HIV, as testing is needed prior to assisted conception because these conditions may have implications for the baby. If your doctor suspects you have endometriosis, you will be referred on for visual identification of the tissue.
If you are overweight, your doctor will advise about the need to reduce weight or limit weight gain. It is unlikely that you will be asked to use temperature charts or ovulation prediction kits in the first instance as there is little evidence to show that they improve success over regular intercourse occurring every couple of days throughout the cycle. If you have a particular medical problem, such as diabetes or heart disease, specialist referral may be required to obtain advice about the effect of this condition on any pregnancy and also the effect of pregnancy on your condition.
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Non-steroidal anti-inflammatory drugs (NSAIDS)
These are used commonly for the treatment of pain, inflammation and fever and can upset ovulation. They interfere with the synthesis of chemical messengers important for the release of the mature egg. So, although the menstrual cycle seems normal and an egg is produced, it is not released. Women who use these medications on a regular basis, such as for chronic arthritis, may encounter difficulty conceiving and stopping the medication may solve the problem.
More specialized assessments
Your initial investigations can be performed by a GP, but more detailed assessment and treatment requires referral to a specialist. There are three key questions, ordered by ease of testing, that will need to be answered:
• do you produce an egg (ovulate) regularly?
• is your partner’s sperm production satisfactory?
• is there any problem with your fallopian tubes that could prevent transport of the egg?