What is infertility? Infertility is defined as the inability to conceive after a year of regular, unprotected sexual intercourse. It can be classified as primary or secondary. Primary infertility refers to couples who have never had a child, while secondary infertility refers to those who have had a pregnancy but are unable to conceive again. The evaluation and causes of infertility are the same for both types. To achieve pregnancy, couples should have intercourse during the woman’s fertile days, which are a few days before and during ovulation. Since pinpointing the exact day of ovulation can be challenging, daily intercourse during the fertile period is recommended to maximize the chances of conception. If pregnancy has not been achieved after a year of frequent intercourse without contraception, the couple should seek evaluation. Sometimes, it is beneficial to seek help even before the one-year mark, especially as a woman’s fertility starts to decline at age 30 and decreases significantly after age 40. Men’s fertility also declines, but more gradually, with some remaining fertile into their 60s or 70s. Evaluation may be initiated sooner if:

• A woman has irregular menstrual cycles, indicating infrequent or irregular ovulation.

• A woman has a history of three or more miscarriages (or if the man had a partner with three or more miscarriages).

• A partner had an infection affecting fertility (e.g., pelvic inflammatory disease, sexually transmitted diseases, or prostate infection).

• A partner is suspected of having fertility issues (e.g., previous unsuccessful attempts to conceive in another relationship).

Causes of Infertility: Infertility can result from disruptions in the complex process of conception. Fertilization typically occurs in the fallopian tube after the egg is released from the ovary. The sperm must reach the fallopian tubes to unite with the egg, forming a zygote. The zygote then travels down the fallopian tube, becoming a morula and eventually a blastocyst, which implants in the uterine lining (endometrium). Infertility can be caused by:

• Ovulation disorders (20%)

• Cervical issues (5%)

• Uterine issues (5%)

• Fallopian tube issues (20%)

• Male factors (30%)

• Unexplained causes (20%)

The main cause of male infertility is low sperm quality, which can involve:

• Oligospermia (low sperm count)

• Azoospermia (no or very little sperm production)

• Abnormal motility (asthenospermia)

• Abnormal sperm morphology

• Sperm abnormalities (either larger or smaller than normal)

• Increased white blood cells in sperm (Leukocytospermia)

• Abnormal coagulation

Lifestyle and daily habits can affect sperm quality. Alcohol, drugs (including marijuana and nicotine), and environmental toxins (e.g., pesticides) can reduce sperm quality. Abnormal sperm production may be congenital or result from medical conditions like mumps, sexually transmitted diseases, testicular injury, or tumors. Inability to ejaculate can also cause infertility and may be due to factors like diabetes, certain medications, prostate or urethral surgery, or erectile dysfunction.

The main cause of female infertility is ovulation disorders, where ovulation does not occur or occurs infrequently. This can be marked by irregular menstrual cycles (oligomenorrhea) or absence of periods (amenorrhea). Lifestyle, stress, diet, and exercise can affect hormonal balance. Rarely, hormonal disorders may result from serious medical conditions like pituitary or hypothalamic tumors, infections, or Turner syndrome. Female infertility can also result from fallopian tube obstruction, caused by adhesions from pelvic inflammation, endometriosis, or ectopic pregnancy. Adhesions can impede fallopian tube mobility or cause distortion between the tube and ovary.

A thorough evaluation can determine the cause of infertility. If medical and sexual history do not reveal the issue, special tests may be necessary.

What (kind of) exams need to be performed?

To assess male infertility, the focus is on examining the quality and quantity of sperm. A semen sample is analyzed under a microscope to check the number of sperm, their shape, and movement. Additional tests may be needed to detect possible infections, hormonal imbalances, or other issues.

For female infertility, a complete history and clinical examination are essential. The first step is to examine the menstrual cycle to determine if ovulation occurs monthly. This can be done using an ovulation test, blood tests to check hormone levels, or an ultrasound examination of the ovaries. Common tests for female infertility include:

• Ultrasound: This is the initial step in assessing fertility, detecting diseases of the cervix, uterus, fallopian tubes, or ovaries. It also evaluates the endometrium and ovaries for their role in infertility. Advanced 3D/4D ultrasound can assess the endometrial cavity and other areas of the female genital system more accurately.

• Hysterosalpingography/Salpingography (HyCoSy or HyFoSy): This special test uses contrast material to visualize the uterus and fallopian tubes, identifying whether the fallopian tubes are open. HyCoSy is less painful and has no radiation compared to classic salpingography.

• Laparoscopy: A small incision is made near the belly button to insert a telescope-like instrument, helping detect conditions inside the abdomen or pelvis.

• Endometrial Biopsy: A small piece of tissue from the lining of the uterus is removed for examination under a microscope to exclude conditions that negatively impact fertility.

Treatment: Based on the test results, appropriate treatments are recommended. In many cases, medication or procedures may be chosen. For women, the most common treatment is to induce ovulation using drugs like clomiphene citrate, gonadotropins, and GnRH analogues. Other drugs, such as bromocriptine and cabergoline, are used when high prolactin levels affect ovarian function. In men, the common issue treated is the obstruction of the seminal vesicles, which can be caused by infections, sexually transmitted diseases, or vasectomy. Artificial insemination and various methods of assisted reproduction are also important tools.

Assisted Reproduction Methods: In some cases, couples may not conceive due to issues like ejaculation problems or sperm not penetrating the vaginal or cervical mucus. Artificial insemination involves placing sperm in the woman’s uterus using a flexible tube. In Vitro Fertilization (IVF) is another technique where the egg is fertilized by the sperm in a laboratory. Initially used for tubal infertility, it is now applied in cases of unexplained infertility, male infertility, endometriosis, and anovulation. Medication is administered to induce ovulation and produce multiple eggs, which are then collected and fertilized in the lab. The fertilized egg is transferred to the uterus. If pregnancy does not occur, the procedure can be repeated in the next cycle.

Other methods include:

• Freezing Eggs and/or Embryos: Eggs are harvested, frozen unfertilized, and stored for later use. They can be thawed, combined with sperm in a lab, and implanted in the uterus.

• IVF with a Donor Egg: Used when the ovaries are malfunctioning, have been removed, or if there is a genetic abnormality. The procedure is the same as IVF, but the eggs are from a donor.

About two-thirds of pregnancies achieved through assisted reproduction are single pregnancies, with most of the remaining being twins. Only a small percentage result in triplets or multiples.