Trouble Conceiving: What to Check, When, and in Whom
Roughly one couple in seven has difficulty conceiving. Two things are worth establishing at the outset: the timeline for seeking help, and the fact that this is not predominantly a female problem.
When to seek help
- After 12 months of regular unprotected intercourse if the woman is under 35
- After 6 months if she is 35 or older
- Straight away if there is known cause for concern: absent or very irregular periods, previous pelvic infection or surgery, endometriosis, previous cancer treatment, undescended testes, or known male factor
Age is the single most important variable. Female fertility declines gradually from the early thirties and more steeply after 35. Male fertility also declines with age, though more slowly.
Male factor is about half
Male factor is the sole cause in roughly 20 to 30 percent of couples and contributes in about half. Despite this, investigation frequently begins and sometimes ends with the woman, which wastes months.
The semen analysis should be among the first tests done. It is cheap, non-invasive and quick. Done properly it needs two to five days of abstinence before the sample, the sample delivered to the lab within an hour at body temperature, and at least two tests several weeks apart before conclusions are drawn, since counts vary considerably.
It measures volume, concentration, total count, motility, progressive motility and morphology. Abnormal results prompt hormone testing, examination for varicocele, which is a common and treatable cause, scrotal ultrasound, and in some cases genetic testing.
Male factors include varicocele, infection, previous mumps orchitis, undescended testes, hormonal problems, genetic conditions such as Klinefelter syndrome, anabolic steroid use which is a significant and often concealed cause, chemotherapy, obesity, heat exposure, smoking, alcohol, and some medications.
Important: exogenous testosterone shuts down sperm production. Men taking testosterone for low levels or for bodybuilding should know this before starting, not after a year of trying.
Female investigation
Is she ovulating? Regular predictable cycles usually mean yes. Confirmed by a mid-luteal progesterone, typically day 21 of a 28-day cycle, adjusted for cycle length.
Hormone profile: FSH, LH, oestradiol, prolactin, thyroid function, and AMH which estimates ovarian reserve. AMH indicates egg quantity, not quality, and does not by itself predict ability to conceive naturally.
Keep reading
The rest of this guide is free. Watch a short ad to unlock it and support independent health writing.
Preparing your ad…
Are the tubes open? Hysterosalpingography, an X-ray with dye, or a hysterosalpingo-contrast sonography. Laparoscopy where endometriosis or adhesions are suspected.
Is the uterus normal? Ultrasound for fibroids, polyps, adenomyosis and congenital anomalies.
Common female factors: ovulation disorders including PCOS, tubal damage from previous infection, endometriosis, fibroids distorting the cavity, premature ovarian insufficiency, and age-related decline.
Unexplained infertility accounts for a significant proportion after all these tests, which is frustrating but does not mean nothing can be done.
Timing intercourse
The fertile window is the five days before ovulation plus the day of ovulation, because sperm survive several days while the egg survives about 24 hours.
Intercourse every two to three days throughout the cycle achieves essentially the same result as elaborate timing, without the stress. Ovulation predictor kits detecting the LH surge can help; basal temperature charts confirm ovulation only after it has happened and are of limited use for timing.
Lubricants matter: most ordinary lubricants impair sperm motility. Use a fertility-friendly product if one is needed.
What both partners can do
- Weight. Both underweight and obesity reduce fertility in women; obesity reduces sperm quality in men. Weight loss in obesity measurably improves conception rates
- Stop smoking. It reduces fertility in both sexes and increases miscarriage
- Limit alcohol. Avoid it when trying to conceive
- Stop anabolic steroids and recreational drugs, including cannabis
- Folic acid 400 mcg daily for the woman, started before conception, with a higher dose in specific circumstances
- Avoid excess heat for men: prolonged hot baths, saunas, laptops on the lap
- Treat chronic conditions: diabetes, thyroid disease, hypertension
- Review medications with a doctor
- Moderate exercise; extreme endurance training can suppress ovulation
- Manage stress, which does not cause infertility but makes the process far harder to live through
Treatments
In rough order of escalation: lifestyle change and timing; ovulation induction with letrozole or clomiphene for anovulation; intrauterine insemination; IVF; and ICSI, where a single sperm is injected into an egg, for significant male factor. Surgery for varicocele, fibroids, polyps or tubal disease where appropriate. Donor gametes and surrogacy where indicated, which in India are governed by specific legislation.
Success rates fall with female age, and clinics should quote live birth rates per cycle for your age group rather than pregnancy rates.
A note on how this is handled
Infertility is medically a couple’s condition and socially, in much of India, treated as the woman’s failure. Both partners should be investigated from the start, both should attend consultations, and no woman should be undergoing invasive testing while her partner has not produced a semen sample.
This is general information. Fertility investigation and treatment should be undertaken with a qualified specialist; be cautious of clinics that recommend IVF before completing basic investigation.