Infertility is the inability to conceive after one year of regular, unprotected intercourse. Around 15% of couples worldwide are affected, and in about half of those cases the issue lies with the woman.
Definition: Primary vs. Secondary Infertility
Primary infertility refers to couples who have never achieved pregnancy. Secondary infertility applies when a couple cannot conceive despite having had at least one previous pregnancy.
Main causes
Female infertility is often multifactorial—hormonal, anatomical, genetic and environmental factors all play a part.
1. Polycystic Ovary Syndrome (PCOS)
PCOS affects 6–10% of women of reproductive age. Insulin resistance and raised androgen levels disrupt or halt ovulation.
- Diagnosis: Rotterdam criteria – irregular cycles, hyperandrogenism, polycystic ovarian appearance on ultrasound.
- Treatment:
- A 5–10% weight loss significantly lowers androgen levels.
- Metformin improves cycle regularity in insulin-resistant patients.
- Letrozole increases live birth rates (27.5% vs. 19.1% with clomiphene; Legro et al. 2014).
2. Ovulation disorders without PCOS
Thyroid dysfunction (hypothyroidism or hyperthyroidism) and hyperprolactinaemia can stop ovulation.
- Testing (cycle days 2–5): TSH, free T3/T4, prolactin.
- Treatment: Levothyroxine for hypothyroidism; dopamine agonists (e.g. bromocriptine) restore ovulation in up to 70% of cases (PubMed 2006).
3. Endometriosis
Endometrial tissue implants outside the uterus, causing inflammation and adhesions.
- Diagnosis: Laparoscopy with histological confirmation.
- Treatment: Minimally invasive excision improves pregnancy rates by 20–30% (WHO 2013).
4. Tubal factor
Damage or blockage of the fallopian tubes—often from infection—prevents egg and embryo transport.
- Diagnosis: Hysterosalpingography (sensitivity 65–95%) (Study 2012).
- Treatment: Tubal flushing or surgical repair restores patency in 40–60%; severe blockages often require IVF.
5. Uterine anomalies and fibroids
Structural issues—such as a uterine septum or fibroids—can impede implantation.
- Diagnosis: 3D ultrasound, hysteroscopy.
- Treatment: Hysteroscopic resection raises live birth rates by 30–40% (RCOG Guideline No. 24).
6. Genetic and immunological factors
Balanced chromosomal rearrangements and antiphospholipid antibodies can prevent implantation.
- Diagnosis: Karyotyping, autoimmune antibody panel.
- Treatment: Low-dose heparin plus aspirin improves implantation rates in antiphospholipid syndrome (Cochrane Review).
7. Idiopathic infertility
Despite thorough evaluation, no cause is found in up to 15% of patients. IUI achieves 10–15% success per cycle; IVF yields 30–35% per cycle.
8. Male factor
A male factor contributes to infertility in about 40% of couples.
- Semen analysis (WHO 2021): >15 million sperm/mL, >40% motility, >4% normal forms (WHO 2021).
Diagnostic workup
- Medical history and cycle logging (length, symptoms, lifestyle)
- Hormonal panel (days 2–5: FSH, LH, AMH, TSH, prolactin, estradiol)
- Transvaginal ultrasound (antral follicle count, fibroids, cysts)
- Hysterosalpingography (assessment of tubal patency)
- Laparoscopy if endometriosis or adhesions are suspected
- Genetic testing for recurrent pregnancy loss
Success rates by age
The German IVF Register (D·I·R) reported (2023) per embryo transfer:
- Under 35 years: 30% live birth rate
- 35–39 years: 20% live birth rate
- 40 years and over: 10% live birth rate
Assisted reproductive techniques: IUI vs. IVF
IUI: 10–15% success per cycle; cost approx. €300–500
IVF: 25–35% live birth rate per cycle; cost approx. €3,000–5,000
Source: ESHRE ART Guidelines
Evaluation timeline
– Women aged 35 and over: begin evaluation after six months of trying
– Women under 35: begin evaluation after 12 months
Source: ESHRE 2015
Clinical checklist
- Record cycle details (basal temperature, cervical mucus, ovulation signs)
- Have medical records and current medication list ready
- Book ultrasound and HSG appointments
- Check your insurance cover for fertility procedures
Lifestyle and nutrition
A BMI of 20–24 kg/m² and a Mediterranean-style diet support reproductive health.
- 400 µg folic acid daily and 1 g omega-3 fatty acids (Study 2016)
- 150 minutes of moderate aerobic exercise per week
- Avoid trans fats and highly processed foods
Environmental toxins
Endocrine disruptors such as BPA and phthalates can damage egg quality.
- Use glass or stainless steel containers instead of plastic
- Choose organic produce to minimise pesticide exposure
- Drink filtered water to reduce PCBs and heavy metals (EFSA 2024)
Conclusion
Female infertility is complex and often multifactorial. A thorough evaluation, evidence-based treatments and tailored lifestyle changes can greatly improve your chances of a successful pregnancy. Collaborate closely with your fertility centre and follow established guidelines on your journey to parenthood.