Infertility is defined as the inability to conceive within 12 months for a couple having regular, unprotected intercourse in the presence of regular menstruation.
Primary infertility is the lack of any previous pregnancy, viable or non-viable, and secondary infertility is where a previous pregnancy has been conceived.
The chances of conception are approximately 80% at 12 months and 90% by 18 months. Hence it is usual to wait 12 months before investigating infertility. This timescale would be dictated by the couple, and advancing maternal age (> 38) may be a reason to commence investigations earlier, along with irregular / absent menses, history suggestive of adhesions or endometriosis and scrotal injury or surgery.
Pregnancy has a 20% chance of occurring in women aged 25 to 35 per cycle. 80 – 90% of women will achieve conception in 12 months, but this decreases with age > 35.
The causes of infertility are varied, but approximately 40% of cases are male related, 50% female related and 10% involve other factors.
Causes of female infertility include ovulation dysfunction (50%), tubal disease (30%), endometriosis (15%) and cervical factors.
A full history and examination should be undertaken to determine the cause of infertility. Whether a woman is ovulating or not can be determined on history, temperature charts and blood or urine tests.
Baseline investigations for the woman include some blood tests and urine tests. This may be followed with an ultrasound. More invasive investigations may be undertaken later e.g laparoscopy
Men should also have a full history and examination done as well as semen analysis because this will determine whether male factors are playing a role. Other investigations such as blood tests can be done as required.
General measures include taking Folic Acid 0.5 mg daily, quitting smoking and losing weight if overweight.
Further management comes down to the cause and will be determined by this. Treatment may consist on ovulation induction with medications, surgery or referral for IVF.
Treatment can be targeted once this initial work-up is complete and the cause of infertility has been isolated. In some couples, a cause cannot be found, however treatment can still proceed to enhance the chances of a pregnancy.