Infertility is defined as the inability to conceive following one year of regular, unprotected intercourse. Approximately 15% of couples worldwide are affected, and in around half of these cases, the problem lies with the woman.
Definition: Primary vs Secondary Infertility
Primary infertility refers to couples who have never conceived. Secondary infertility applies when a couple is unable to conceive despite having had at least one previous pregnancy.
Main Causes
Female infertility often has multifactorial origins—hormonal, anatomical, genetic and environmental.
1. Polycystic Ovary Syndrome (PCOS)
PCOS affects 6–10% of women of reproductive age. Insulin resistance and elevated androgen levels disrupt or halt ovulation.
- Diagnosis: Rotterdam criteria – irregular cycles, hyperandrogenism, polycystic ovarian appearance on ultrasound.
- Treatment:
- A 5–10% reduction in body weight markedly 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 inhibit 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 the egg and embryo from travelling through.
- 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 successful implantation.
- Diagnosis: Karyotyping, autoimmune antibody panel.
- Treatment: Low-dose heparin plus aspirin improves implantation rates in antiphospholipid syndrome (Cochrane Review).
7. Idiopathic Infertility
No cause is identified in up to 15% of patients despite thorough evaluation. IUI offers 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 charting (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 in 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 Conception 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 twelve months
Source: ESHRE 2015
Clinical Checklist
- Record cycle details (basal temperature, cervical mucus, ovulation signs)
- Prepare medical records and current medication list
- 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 impair egg quality.
- Use glass or stainless steel containers instead of plastic
- Opt for 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.