​​Infertility – A Helping Guide

This guide is created by the Bumpy team to support you and has been reviewed by our medical experts and advisors. It is specifically focused on providing information, causes, diagnosis, and treatments related to infertility. The intention is to help patients gain a better understanding of infertility and find assistance through this article.

The whole guide includes four sections:

I. Overview

II. Causes

III. Diagnosis

IV. Treatments

I. Overview

What is Infertility?

Infertility is a medical condition that affects both the male and female reproductive systems, resulting in the inability to achieve a pregnancy despite regular unprotected sexual intercourse for a period of 12 months or more. It is a widespread issue with significant implications for individuals, their families, and communities worldwide. Statistics indicate that approximately one in six individuals of reproductive age will experience infertility during their lifetime.

In males, infertility often arises from difficulties in ejaculating semen, low sperm count or absence of sperm, as well as abnormalities in sperm shape (morphology) and movement (motility).

For females, infertility can be attributed to various abnormalities within the reproductive system, including but not limited to issues with the ovaries, uterus, fallopian tubes, and hormonal imbalances.

Infertility is categorized into two types: primary and secondary. Primary infertility occurs when a person has never achieved a pregnancy, whereas secondary infertility refers to the inability to conceive after having had at least one prior successful pregnancy.

Fertility care encompasses a range of measures aimed at preventing, diagnosing, and treating infertility.

II. Causes of Infertility

Infertility can stem from various causes and may affect either partner in a relationship. However, in up to 25% of cases, the specific cause cannot be identified.

Common causes of infertility include:

Irregular Ovulation:

Inadequate or inconsistent release of eggs during the monthly menstrual cycle.

Poor Semen Quality:

Abnormalities in the quality of semen, which may impact sperm count, motility, or morphology.

Blocked or Damaged Fallopian Tubes:

Obstructions or damage to the fallopian tubes that prevent the fertilization of the egg.

Endometriosis:

A condition where tissue resembling the uterine lining grows outside the uterus, leading to fertility issues.

Male infertility accounts for 20–30% of infertility cases, while 20–35% are attributed to female infertility. Approximately 25–40% of cases involve combined issues affecting both partners, and in 15–25% of cases, no identifiable cause can be found. Among females, ovulation problems, often marked by infrequent or absent menstrual periods, are the most common cause of infertility. Male infertility is frequently associated with semen deficiencies, and semen quality is used as an indicator of male fecundity.

Several factors may influence fertility. These include:

Age:

Fertility declines with age. A woman's peak reproductive years are between the late teens and late 20s. Fertility gradually starts to decrease by the age of 30. This decline becomes more rapid after the age of 35. A healthy woman in her 20s has a 25-30% chance of getting pregnant every month. By age 40, the chance of getting pregnant in any monthly cycle is around 5%. By 45, fertility has declined so much that getting pregnant naturally is unlikely for most women. Age also affects male fertility although decline is slower and starts later than in the woman.

Weight:

Being overweight or obese (having a BMI of 30 or higher) can reduce fertility. In women, both overweight and severe underweight conditions can affect ovulation.

Sexually Transmitted Infections (STIs):

Certain STIs, such as chlamydia, can have adverse effects on fertility.

Smoking:

Smoking, including passive smoking, can decrease the chances of conceiving and impair semen quality. Quitting smoking is advisable.

Alcohol:

Excessive alcohol consumption can impact sperm quality. It is recommended to minimize alcohol consumption.

Environmental Factors:

Exposure to specific pesticides, solvents, and metals has been linked to fertility issues, particularly in males.

There is no evidence suggesting that caffeinated beverages like tea, coffee, and soft drinks are associated with fertility problems however there are some studies that found women who drink large amounts of caffeine may take longer to get pregnant or may have higher risk of a miscarriage. Often nutritionists recommend no more than 2 cups daily.There are a variety of factors that can result in infertility. Both men and women could potentially experience fertility issues

Causes of Female Infertility

Ovulation issues

Infertility often arises due to issues related to ovulation, which involves the monthly discharge of an egg from the ovaries. Some challenges lead to a complete lack of egg release, while others result in irregular release patterns across cycles.

Ovulation complications can stem from:

1. Polycystic ovary syndrome (PCOS)

2. Thyroid abnormalities – excessive or insufficient thyroid activity can impede ovulation

3. Premature ovarian failure – ovaries ceasing to function prior to turning 40

Effects of Surgical Scarring

Procedures in the pelvic region can lead to scarring that affects the fallopian tubes, vital connections between the ovaries and the uterus. Similarly, cervical surgeries might result in scarring or the shortening of the cervical neck, impacting the structure of the womb.

Impact of fibroids

Non-cancerous growths known as fibroids, whether within or surrounding the uterus, can have implications for fertility. These growths might hinder the attachment of a fertilized egg within the womb or obstruct a fallopian tube in certain instances.

Endometriosis's effect on fertility

Endometriosis involves the growth of fragments of the uterine lining (endometrium) in locations beyond the womb, like the ovaries. This may lead to adhesions, affecting mobility of the Fallopian tubes, and an inflammatory state in the pelvic cavity, which will affect fertilization between the oocyte and the sperms as well as transport through the Fallopian tube.

Impact of Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) pertains to an infection affecting the upper reproductive tract in females, encompassing the uterus, fallopian tubes, and ovaries. Typically arising from sexually transmitted infections (STIs), PID can lead to scarring and impairment of the fallopian tubes, severely hampering the egg's journey into the uterus.

Sterilization's Impact on Fertility

Certain women opt for sterilization when they no longer wish to have additional children. This procedure involves obstructing the fallopian tubes to prevent the egg's passage to the uterus. Reversing sterilization is seldom possible and does not guarantee the ability to conceive afterward.

Uterine malformations

Uterine malformations, such as septum in the uterus or that the the uterus is divided into two separate horns may affect infertility.

Medications and Their Impact on Fertility

The potential effects of certain medications and drugs on fertility should be considered. These include:

Non-steroidal anti-inflammatory drugs (NSAIDs):

Prolonged use or high doses of NSAIDs, like ibuprofen or aspirin, may complicate conception.

Chemotherapy:

Some chemotherapy medications can lead to ovarian failure, diminishing ovarian function.

Neuroleptic medicines:

Antipsychotic drugs utilized for treating psychosis might cause irregular periods or infertility.

Spironolactone:

A medicine employed to address fluid retention, fertility typically rebounds within about 2 months after discontinuing spironolactone.

Furthermore, illegal drugs, such as marijuana and cocaine, can significantly impact fertility and disrupt ovulation processes.

Causes of Male Infertility

A frequent cause of male infertility stems from subpar semen quality, the fluid encompassing sperm released during sexual intercourse.

Potential culprits for unusual semen characteristics encompass:

Sperm deficiency:

This may manifest as an extremely low sperm count or the absence of sperm altogether.

Sperm motility issues:

Poorly mobile sperm face difficulties in reaching the egg.

Abnormal sperm morphology:

Sperm with atypical shapes might encounter challenges in movement and egg fertilization.

Many instances of abnormal semen remain without a definitive explanation.While a connection exists between elevated scrotal temperature and diminished semen quality, it remains uncertain whether wearing loose-fitting underwear contributes to improved fertility.

Testicular impact on semen

The testicles serve as the site for sperm production and storage. Impairment to the testicles can profoundly influence semen quality.

Such damage may arise from:

Testicular infection:

Infections affecting the testicles can lead to damage.

Testicular cancer:

Presence of testicular cancer can also compromise testicular function.

Testicular surgery:

Surgical interventions involving the testicles can result in damage.

Congenital defects:

Inherited testicular abnormalities can contribute.

Undescended testicles:

When one or both testicles fail to descend into the scrotum.

Testicular injury:

Trauma to the testicles can lead to damage affecting semen quality.

Male Sterilization: Vasectomy

Certain men opt for a vasectomy when they wish to remain childless or have no further children. This procedure entails severing and sealing the tubes (vas deferens) responsible for transporting sperm from the testicles, resulting in semen without sperm content. While vasectomy reversals are feasible, they often yield limited success.

Ejaculatory Dysfunction

Certain men encounter challenges related to ejaculation, which can hinder the release of semen during sexual activity.

Hypogonadism and Testosterone

Hypogonadism refers to an unusually low level of testosterone, the key male sex hormone essential for sperm production. Potential triggers encompass tumor development, illicit drug usage, or Klinefelter syndrome, a rare condition characterized by an additional female chromosome.

Impact of medications on male fertility

Impact of medications on male fertility Certain medications can occasionally give rise to fertility issues in men. These include:

Sulfasalazine:

An anti-inflammatory drug used to treat conditions like Crohn's disease and rheumatoid arthritis; temporary decrease in sperm count is possible, and count should rebound once usage stops.

Anabolic steroids:

Illegally used to enhance muscle growth and athletic performance; chronic steroid misuse can lower sperm count and mobility. This usually gives irreversible damage and the period of anabolic steroid drug use may be several years before the infertility diagnosis is made.

Chemotherapy:

Some chemotherapy drugs may considerably impair sperm production.

Herbal remedies:

Certain herbal treatments, like extracts from the Chinese herb Tripterygium wilfordii, might influence sperm production or testicle size reduction.

Moreover, illegal substances such as marijuana and cocaine can also impact the quality of semen.

Unexplained Fertility Challenges

Unexplained infertility occurs when no discernible cause is evident in either partner.

In situations where the root cause of fertility difficulties remains unidentified, it's advised to consult a fertility specialist regarding subsequent actions. For those of you facing unexplained infertility and who haven't achieved conception despite 12 months of consistent unprotected intercourse, the recommendation is to consider IVF treatment.

III. Seeking Help & Diagnosis

While some individuals achieve pregnancy quickly, others may experience a longer journey. If you have been actively trying to conceive for a year or more without success, it is advisable to seek medical guidance. Women who are 35 years or older, as well as those who suspect they may have fertility issues, should consult a physician sooner.

A medical professional can then assess common causes of fertility problems and recommend appropriate treatments. To learn more about the diagnostic process for infertility, we encourage you to continue reading and explore our resources.

When to seek medical assistance?

If you've been attempting to conceive for a year without success, it's advisable to consult a gynecologist or fertility expert.

However, we recommend to seek a consultation sooner (within 6 months) if:

1. You're a woman aged 35 or older as fertility decline accelerates as you approach your mid-30s

2. You have concerns about your fertility due to factors like a known medical condition that may impact fertility, cancer treatment or potential exposure to sexually transmitted infections (STIs).

3. You have Endometriosis and continued hormonal treatment is needed.

Where to seek care for a fertility investigation?

Contact a gynecological clinic, a women's health clinic or a fertility clinic for infertility investigations or treatment. You can find a list of these here in the Bumpy app.

You can also seek help at your healthcare center (vårdcentral), where a doctor can make a referral to the appropriate specialist or clinic.

During the initial consultation, the physician will evaluate potential factors contributing to fertility challenges and offer guidance on subsequent steps. It's important for both partners to visit the physician, as fertility issues can impact either individual or both.

During the first consultation your doctor will inquiries about the following:

 •  Medical background

 •  Previous births or complication, miscarriages

 •  Duration of conception attempts

 •  Intimate relations

 •  Medication and Contraceptive Cessation

 •  Lifestyle

Medical conditions you currently or previously experienced, including sexually transmitted infections (STIs), will be discussed. Women will be asked about the regularity of their menstrual cycles, as well as any occurrences of bleeding between periods or post-sex.

Discussions about miscarriages, previous births and potential complications in prior pregnancies will also be addressed.

Questions concerning the frequency of sexual activity and any encountered difficulties may arise. Although discussing your intimate life with the doctor might feel uneasy, being candid is essential. If fertility issues are linked to sexual activity, they could potentially be addressed with relative ease.

Medications that you're currently taking will be reviewed, as some could impact fertility and alternative treatment options may be explored if needed. Be sure to mention any non-prescription medications, herbal remedies, or supplements.

The type of contraception previously used and the date of cessation will be topics of conversation. Some contraceptive methods take time to cease their effects, which could be affecting fertility.

Lifestyle choices can influence fertility. Expect queries regarding smoking, weight, alcohol consumption, illicit drug use and stress. Recommendations for lifestyle adjustments might be proposed to enhance your chances of conceiving.

Following these inquiries, your doctor may conduct a physical examination or suggest further tests as necessary to evaluate your fertility.

Fertility evaluation and investigations

An investigation can sometimes explain infertility. Fertility investigation can take a few months, but it is different at different clinics. An investigation includes several different samples and tests. Important to note that sometimes no reason for infertility is found.

Assessment of Female Fertility

Determining the factors contributing to female infertility involves a series of targeted tests designed to unveil underlying causes. An examination can show whether the ovaries, ovulation, fallopian tubes and uterus are working properly. These assessments encompass a range of approaches, each shedding light on specific aspects of reproductive health:

Ovulation Testing:

To test whether you are ovulating, you can use so-called LH sticks. LH is a hormone that is secreted in the body about a day and a half before ovulation. LH hormone is then present in the urine for a day or two. When you pee on the stick, it is possible to read whether the hormone is present in the body. You do the test yourself at home.

Hormone Profiling via Blood Tests:

Blood samples are analyzed to evaluate hormone levels, particularly progesterone, a key indicator of ovulation. The timing of these tests is tailored to your menstrual regularity. If irregular periods are noted, hormone levels known as gonadotrophins and prolaction, could be measured.

Transvaginal Ultrasound:

This procedure involves inserting an ultrasound probe into the vagina to assess the health of the uterus and ovaries and to identify any fallopian tube obstructions. Ultrasound technology is employed to meticulously examine the ovaries, uterus, and fallopian tubes. Notably, conditions such as endometriosis and fibroids can hinder pregnancy. Furthermore, the scan is utilized to identify potential blockages within the fallopian tubes, which may hinder the passage of eggs. In the event of possible blockages, a referral to a specialist and discussions regarding additional assessments may follow.

Collectively, these diagnostic methods offer a comprehensive assessment of reproductive health, enabling healthcare professionals to pinpoint causes of infertility in women.

Assessment of Male Fertility

The investigation into male infertility involves a series of targeted tests aimed at uncovering the underlying causes. These assessments focus on specific aspects of reproductive health and include:

Semen Analysis:

A semen sample is collected for semen analysis – a crucial evaluation that examines sperm quality, quantity, and motility. This analysis measures total sperm count, concentration and motility (swimming) of sperms. The sperm must be fresh at the time of the test. At the clinic, there are usually special rooms where you can masturbate. It is also fine to masturbate at home if you can transport the semen to the clinic within a certain time. You get a jar to keep the sperm in. Then the sperm must be kept warm and the semen needs to get to the clinic within about an hour of ejaculation. You may be given another sample If it shows that the sperm are few or move poorly you may give another sample. If the second test also shows the same poor result as the first it is likely that the sperm is the cause of the infertility.

When all the tests have been done and the investigation is complete, you and the doctor can discuss which treatment might suit you best and you might be approved to commence treatment at a fertility clinic.

Sometimes the doctor assesses that the chance of getting pregnant is good and that you do not need any treatment, but can try a little more yourself. Sometimes the doctor can determine that there are no eggs or sperm and you might be recommended to consider egg or sperm donation.

IV. Treatment

Treatment depends on the cause of infertility, how long you’ve been infertile, your age and your partner’s age (if you have a partner) and personal preferences.

Fertility treatments encompass a range of options yet the main three primary categories are:

Medical Treatment:

In this category, various medications are utilized to address underlying factors impacting fertility. These can include hormone imbalances, irregular ovulation, or other issues that affect reproductive health. Fertility medications are often aromatase inhibitors (tablet; letrozol) or FSH (subcutaneous injection) to enhance ovulation and dopamine agonists to decrease high prolactin levels, regulate hormonal levels, and improve the chances of conception.

Surgical Procedures:

Surgical interventions are employed to treat anatomical abnormalities or conditions that hinder fertility in men and women. Surgical interventions aim to restore or improve the reproductive organs' functionality and create a more conducive environment for conception. For women a surgical procedure may be considered to treat conditions such as endometriosis, repair fallopian tube blockages, or remove adhesions within the uterus or abdominal cavity. For men surgical sperm extraction (TESE): can be used if there are extremely low numbers of sperm in the semen, you may be able to have sperm collected surgically.

Assisted Conception Techniques:

This category encompasses advanced medical procedures designed to aid conception when natural methods prove ineffective. Two most commonly utilized are intrauterine insemination (IUI) and in vitro fertilization (IVF) however we have outlined a range of assisted conception methods below.

- Intrauterine Insemination (IUI):

IUI involves placing carefully prepared sperm directly into the uterus during the woman's ovulation period. This technique enhances the chances of sperm reaching and fertilizing the egg. Read more on IUI here ->

- In Vitro Fertilization (IVF):

IVF is a comprehensive fertility treatment involving the stimulation of egg production, retrieval, fertilization outside the body, and subsequent implantation of the embryo into the uterus. IVF is particularly effective for various fertility challenges and offers a higher degree of control over the conception process. Read more on IVF here ->

- IVF options:

It’s possible to have IVF with either less medication, or no medication at all. These treatments include natural IVF, mild stimulation IVF and in vitro maturation (IVM) and may be suitable for people who are unable to take fertility drugs due to an existing medical condition.

- Gamete & Embryo Donation:

Gamete and embryo donation is using eggs, sperm, or embryos from someone else in order to help an intended parent(s) have a child. Intended parent is the term used for the person(s) who will raise the child(ren).

- Intra-Cytoplasmic Sperm Injection (ICSI):

ICSI is used to achieve possibilities for fertilization where there is a male factor problem. It involves an embryologist selecting a single sperm and injecting it into the egg. However, it is an invasive procedure and used in around 30% of IVF procedures. In conventional IVF, natural selection chooses the best sperm to fertilize the egg. In ICSI, we are reliant on human choice.

- Preimplantation Genetic Testing (PGT):

PGT is a cutting-edge procedure used to identify genetic abnormalities in embryos created with in vitro fertilization. This is predominantly used when facing the prospect of a serious genetic condition within your family. The goal of PGT is to be able to select embryos predicted to be free of a specific genetic condition or chromosome abnormalities for transfer. Due to the possibility of gender selection, this procedure is only available to prevent genetic disease in some markets.

These three overarching categories represent the diverse range of fertility treatment options available to individuals and couples facing challenges in achieving pregnancy. Each approach is tailored to the specific needs and circumstances of the individuals involved, with the goal of enabling successful conception and a healthy pregnancy.

The specific treatment recommended will depend on the underlying cause of fertility problems and the available options within your local integrated national care. It is worth noting that private treatment options are also available; however, they can be costly. If considering private treatment, or treatment abroad it is essential to carefully select a reputable clinic. Seeking advice from a physician and utilizing resources like the Bumpy app can help guide your decision-making process (more on the further down).

Treatment risks

In general fertility treatments are very safe. However, there are some risks to be aware of, which range from mild discomfort to more serious conditions. From short term to longer term, these risks include:

Stress:

Going through infertility itself can be very stressful yet doing fertility treatments can add to that stress as it can be draining for the body, mind and finances. Support from counselors, family, friends and our community can help you through the ups and downs of fertility treatment.

Ovarian hyperstimulation syndrome (OHSS):

This condition is an exaggerated response to excess hormones. Symptoms of ovarian hyperstimulation syndrome often begin within a week after using injectable medications to stimulate ovulation, though sometimes it can take two weeks or longer for symptoms to appear. They include belly pain, bloating, upset stomach, vomiting and diarrhea. Rarely, some people get a worse form of ovarian hyperstimulation syndrome that also can cause rapid weight gain and shortness of breath. It occurs in less than 2% of women undergoing IVF.

Miscarriage:

Miscarriages are common and even though the rate of miscarriage for people who conceive using IVF is similar to that of people who conceive naturally, it is important to acknowledge that there is a possibility of a miscarriages to occur.

Ectopic pregnancy:

This is a condition in which a fertilized egg attaches to tissue outside the uterus, often in a fallopian tube. The embryo can't survive outside the uterus, and there's no way to continue the pregnancy. The incidence of ectopic pregnancy is higher after in vitro fertilization than in spontaneous pregnancies however it is a small percentage of people who will have an ectopic pregnancy. If you have any signs or symptoms of an ectopic pregnancy, including severe abdominal or pelvic pain accompanied by vaginal bleeding, extreme lightheadedness or fainting, seek emergency medical help immediately.

Multiple pregnancy:

IVF raises the risk of having more than one baby. Becoming pregnant with multiple babies carries higher risks of pregnancy-related high blood pressure and diabetes, early labor and delivery, low birth weight, and birth defects than does pregnancy with a single baby.

Premature delivery and low birth weight:

Research suggests that IVF slightly raises the risk that the baby will be born early or with a low birth weight.

Choosing a clinic

Deciding which clinic best meets your needs can feel a bit overwhelming. It may be tempting to rely solely on success rates but the reality is that most clinics are broadly good, small differences in rates are usually down to the different types of patients treated.

Finding out how other patients rate the clinic and their experience, the clinic’s opening hours, location and whether they have a female doctor could all be equally important factors to consider.

Some of the factors you may wish to consider when choosing a clinic include:

 •  Treatments offered

 •  Eligibility criteria

 •  Cost of treatment

 •  Location (bear in mind you’ll need to make multiple trips to your clinic, sometimes at short notice)

 •  How other patients have rated the clinic

 •  Patient experiences

 •  The clinic’s success rates

 •  Waiting times

 •  Counseling provision/mental health support

To access more information about clinics, we recommend using our app.

Find and compare clinics ->

Additionally, we provide a supportive community where you can engage with others who have similar experiences, share valuable tips, gain insights and share your journey

Support Community ->