Overview

Infertility is a global health issue affecting millions of couples. It is defined as being unable to conceive after a year of regular and unprotected intercourse. Fertility challenges can be physically and emotionally draining. This makes the parenthood journey stressful and complex. Infertility can arise from problems affecting one or both partners. Both the partners’ age, lifestyle, and existing medical conditions can also play significant roles in fertility. Many effective and safe treatment options are available if you are going through this challenging time to have a baby. Knowing when to seek professional help is important to transform this challenging journey into the pursuit of parenthood.

Importance of seeking professional help

It is very important to seek professional help during this difficult journey. Seeking help is crucial for 

• Early diagnosis 
• Personalised treatment 
• Emotional and financial support 

This results in an improved success rate. Early intervention helps in the safe management of treatments and minimises health risks. Regardless of gender, it is important to seek early professional help if you have a risk factor or medical condition that affects fertility. Prompt evaluation is crucial for those with a history of primary ovarian failure or severe endometriosis.

What are the common causes of infertility?

As mentioned above, infertility is defined as the inability to conceive after 12 months of regular, unprotected sexual intercourse. Approximately 85% of infertile couples have an identifiable cause. The most common include ovulatory disorders and male factor infertility. The remaining 15% experience unexplained infertility. Lifestyle and environmental factors, such as obesity and smoking, can also affect fertility.¹

Disorders affecting the fertility of people assigned female at birth

There are several disorders that affect the fertility of people assigned female at birth (AFAB). 

Ovulatory disorders

Ovulation is a process in which an egg is released from an ovary. Regular menstrual cycles with symptoms like breast tenderness usually mean ovulation is happening. Ovulatory disorders cause about 25% of infertility cases. Lack of ovulation might be suspected if:¹ 

1. Periods are irregular 
2. Shorter than 21 days 
3. Longer than 35 days
4. There's unusual bleeding or no periods 

Ovulation typically occurs 14 days before the next period.

Common reasons for not ovulating are:¹

• Polycystic ovary syndrome (PCOS), affecting 70% of people AFAB with this problem 
• Obesity also causes anovulation. People AFAB with a BMI over 27 are more likely to have this issue compared to those with a normal BMI
• Thyroid disease
• Hormonal issues
• Unknown reasons
• Issues from being underweight, having eating disorders, or engaging in too much exercise. People AFAB with eating disorders often face more infertility problems than those without them

Tubal factors

Tubal infertility means that either the fallopian tubes are blocked or they cannot pick up an egg from the ovary due to pelvic scars. It should be considered if a person AFAB has a history of sexually transmitted infections.¹

Uterine or cervical abnormalities

Uterine or cervical problems can affect fertility:

• Polyps or tumours: Uterine fibroids or polyps can block tubes or affect implantation
• Congenital uterine problem: An unusually shaped uterus can cause pregnancy issues
• Cervical stenosis: Narrowing of the cervix can block sperm
• Cervical mucus abnormalities: Problems with mucus can prevent sperm from reaching the uterus

Endometriosis

Endometriosis is a condition where tissues that are like the womb's lining grow outside the uterus. For example, this lining might grow on the ovaries and in the fallopian tubes. Endometriosis can affect people AFAB of any age. Furthermore, it is a long-term issue that can significantly impact fertility.

Disorders affecting the fertility of people assigned male at birth

Infertility impacting people assigned male at birth (AMAB) can result from various factors. These factors include:² 

1. Problems with sperm 
2. Lifestyle choices 
3. Medical conditions 
4. Medications 

Infertility of people AMAB can be caused by various factors, including:³

• Sperm issues: Malformed sperm, low sperm count (oligospermia), or no sperm in semen (azoospermia)
• Genetic disorders
• Medical conditions like diabetes and autoimmune diseases that affect the sperm
• Infections like sexually transmitted infections (STIs) like gonorrhoea or HIV
• Swollen veins in the testicles
• Cancer treatments: Chemotherapy, radiation, or testicle removal
• Testicular injury: Trauma to the testicles
• Hormonal disorders: Problems with the hypothalamus or pituitary glands
• Unexplained infertility: In many cases, the cause of infertility remains unknown and is classified as idiopathic or unexplained

Age

Advanced age of people AFAB is associated with fewer and poorer-quality follicles, as well as a higher risk of miscarriage.⁴

Initial steps before seeking professional help

Before seeking professional assistance, couples can take several proactive steps to enhance their chance of conception: 

1. Tracking menstrual cycles 
2. Maintaining a healthy diet and lifestyle 
3. Using ovulation prediction kits
4. Understanding the best times for intercourse 

All of these steps can improve the chances of conception. 

Monitoring menstrual cycle and ovulation

The best time to get pregnant is on the day of ovulation. It usually happens 14 days before the next period. For a 28-day cycle, it is day 14 and for a 32-day cycle, it is day 18. 

To exactly determine the day of ovulation, check the body temperature of the person AFAB every morning before they get out of bed. These temperatures should then be written down. A drop in temperature followed by a rise of more than 0.5°C shows ovulation. In future cycles, you should time intercourse for this day to improve the chances of conception.⁵

Maintaining a healthy lifestyle

Since obesity is associated with reduced fertility, physicians often recommend weight loss to obese people AFAB trying to conceive. They are also advised to maintain a healthy lifestyle. A healthy preconception diet and weight loss through proper weight management can improve pregnancy outcomes and increase fertility.⁶ People AFAB trying to conceive should be encouraged to abstain from alcohol and reduce their caffeine intake.⁷

When to seek professional help

The American Society of Reproductive Medicine defines infertility as not getting pregnant after 12 months of regular, unprotected sex. If medical history or exams suggest problems, or if a person AFAB is over 35 and hasn’t conceived after 6 months, it's recommended to seek treatment sooner. For people AFAB under 35, a regular cycle usually shows ovulation. Heavy bleeding could indicate the formation of polyps or fibroids, and severe pain might suggest endometriosis. Irregular or missing periods could mean problems like a lack of ovulation or issues with the uterine lining. People AFAB with frequent miscarriages or pregnancy issues may need extra tests.⁸

Professional evaluation and diagnosis of infertility

Diagnosing infertility starts with a detailed history, focusing on how long the couple have been trying to conceive. It also includes key factors like the age and menstrual cycle of the person AFAB. Regular cycles suggest ovulation, while heavy bleeding or pain might indicate issues like polyps or endometriosis. Irregular periods could signal problems with ovulation or the uterus.

Tests to diagnose infertility of people AFAB

Key tests for people AFAB include:⁸

• Antral follicle count
• Clomiphene citrate challenge
• Measuring hormone levels (AMH, FSH, LH, prolactin, TSH, estradiol (a type of oestrogen), progesterone)
• Hysterosalpingogram (HSG)
• Diagnostic hysteroscopy and laparoscopy

Tests to diagnose infertility of people AMAB

 To diagnose the infertility of people AMAB, the tests include:⁸

• Semen analysis
• Antisperm antibody test
• Genetic tests (for cystic fibrosis and chromosomal issues)
• Checking hormone levels (LH, FSH, prolactin, testosterone)
• Semen leukocyte count
• Post-ejaculatory urinalysis
• Ultrasound of the scrotum, testicles, or rectum
• Testicular biopsy
• Vasography/vasogram

Treatment options for infertility

Based on the diagnosis, several treatment options are available. Common infertility treatments include:¹

• Ovulation induction: Use of medications to trigger ovulation
• Ovarian stimulation: Aiming to produce multiple mature follicles
• Timed intercourse or intrauterine insemination (IUI): Both methods aim to fertilise the egg at ovulation
• In vitro fertilisation (IVF): Retrieving eggs from the ovary using an ultrasound-guided needle for fertilisation
• In third-party assisted reproductive technology (ART), couples may use donor eggs, donor sperm or donor embryos. Some couples may also opt for a gestational carrier or surrogate
• Surgery: Some men may need surgery to remove blockages in the tubes that carry sperm or to fix structural issues. Varicocelectomy can help in improving sperm health and increase the chances of getting pregnant

Emotional and psychological support

Patients undergoing infertility treatment also experience anxiety and depression. Infertility patients frequently face stress, anxiety, and depression. Anxiety is a normal response to stress. However, when it becomes excessive, it needs medical attention.⁹ Therefore, it is crucial for infertility providers and counsellors to offer psychological interventions and emotional support to help these patients.¹⁰ Effective psychosocial care is key in fertility treatment. Fertility clinics should provide patient-centred support through staff and specialised counsellors. Counselling should address 

1. Emotional needs 
2. Gender differences and 
3. Decision-making about third-party reproduction 

Clinics should decide on internal or external counselling. Furthermore, clinics should also use screening tools to assess and refer patients appropriately. This approach improves patient outcomes and quality of life.¹¹

Conclusion

In conclusion, coping with infertility can be emotionally challenging due to uncertainties in the process. Being prepared, understanding the steps, and setting emotional limits can help manage stress. Seeking support from groups or counsellors is beneficial. Infertility's emotional impact and stress from unsuccessful treatments can affect relationships and mental health. Professional help from a therapist can be crucial.

For evaluation, consult a family doctor to determine if specialist care is needed for both partners. Different treatment options such as medication, surgery and IVF are available to embark on the journey of parenthood. By getting timely professional help, couples can understand fertility challenges and can enhance their chances of getting pregnant.

Summary

Infertility is a serious issue affecting couples all around the world. It is defined as being unable to conceive after 12 months of regular, unprotected sexual intercourse. If proactive steps such as monitoring the menstrual cycle and ovulation and maintaining a healthy lifestyle are not enough to conceive, professional help might be necessary.

There are a multitude of disorders which can impact the fertility of people assigned female at birth and of people assigned male at birth. In most cases, performing all the appropriate evaluations and tests will allow healthcare professionals to diagnose the cause of the infertility.

If the cause can be identified, the corresponding treatment should be started as soon as possible to boost the chances of successfully conceiving a child. At the same time, the emotional and psychological toll on those afflicted with infertility needs to be addressed and treated as well.