An in-depth guide to infertility: part 1

Infertility is when a couple is unable to conceive after a year or more of regular, unprotected sex. It is estimated that it affects 1 in 7 couples in the UK and can be associated with psychological distress and significant strain to the relationship if prolonged treatment is unsuccessful. In the first article of a two-part series, revered consultant gynaecologist and specialist in fertility Miss Petya Doncheva provides an in-depth guide, explaining the signs of infertility in women, causes and diagnosis.

What are the signs and symptoms of infertility in women?

It is essential that couples who are trying to conceive are seen together for an initial assessment in order to review their lifestyle and sexual history and identify the couples that are less likely to conceive. For the majority of women, it is acceptable to offer initial assessment and investigations after one year of trying to conceive. However, women aged 36 and above and those with risk factors such as irregular cycles, known endometriosis, history of pelvic surgery or infections, difficulties in achieving regular intercourse or previous cancer treatment, should be offered an earlier assessment to provide timely fertility treatment.

Symptoms that indicate ovulatory disorders include infrequent and irregular menstrual cycles or lack of periods, painful or heavy periods, excessive hair growth, acne, weight gain or weight loss. Other symptoms may include longstanding pelvic pain or painful intercourse (in women with underlying endometriosis), offensive vaginal discharge, intermenstrual bleeding or bleeding after intercourse (in pelvic inflammatory disease).

Risk factors for infertility are advanced female age, high or low BMI, lifestyle factors, underlying medical conditions, and stress. Upon examination, an abnormal BMI, whether high or low, may suggest anovulation. Symptoms such as acne, excessive hair growth, and galactorrhoea (milk secretion from the breast in a non-breastfeeding woman) can indicate polycystic ovarian syndrome and elevated prolactin levels, respectively. A pelvic examination may reveal abnormal pelvic masses like ovarian cysts or large fibroids, as well as vaginal discharge or tenderness during a speculum examination.

What are the leading causes of female infertility?

Ovulatory disorders are the most common cause of female infertility affecting around 1 in 5 women trying to conceive. Polycystic ovarian syndrome is responsible for most ovulation disorders. Other causes can be associated with dysfunction of the hypothalamus, pituitary gland, thyroid gland or has ovarian origin.

Tubal damage comes second and affects 1 in 6 women with delayed conception. The most common cause is a history of pelvic inflammatory disease secondary to Chlamydia trachomatis, Neisseria gonorrhoea or anaerobic infections. It is important to note that tubal damage occurs in about 10% of women after one episode of pelvic infection, 23-35% after two episodes and 55-75% after three episodes. This condition can be associated with longstanding pelvic pain and increases significantly the risk of ectopic pregnancy. Other inflammatory conditions such as bowel disease or appendicitis can also be associated with tubal damage.

Uterine disorders such as polyps, fibroids, intrauterine adhesions or congenital uterine anomalies affect around 10-15% of subfertile women. The majority of those can be managed effectively with surgical interventions.

It is estimated that 25-40% of women diagnosed with infertility have some form of endometriosis. This condition can impact fertility in various ways, including causing pelvic inflammation and adhesions that affect the fallopian tubes. Endometriosis can also lead to pelvic pain, reducing the quality of life and the frequency of intercourse. Additionally, it is associated with immunological changes and reduced implantation rates.

Approximately 40% of women undergoing routine investigations for infertility have no identifiable cause and are thus diagnosed with unexplained infertility.

How is infertility diagnosed in women?

When investigating infertility, it's crucial to examine both partners simultaneously, as mixed causes are present in about 40% of couples. For women trying to conceive, mid-luteal progesterone levels should be measured to confirm ovulation, even if they have regular cycles. If progesterone levels indicate anovulation, further investigations, including a pelvic scan and a further hormonal profile, are necessary.

Routine testing for prolactin and thyroid function should be reserved for women exhibiting symptoms such as irregular cycles, galactorrhoea, or signs of thyroid dysfunction. A pelvic scan is essential to evaluate the uterus for polyps, fibroids, or anomalies, with a 3D scan recommended for detailed assessment. This scan also checks ovarian reserve, ovarian mobility, and the presence of ovarian cysts or dilated fallopian tubes.

To exclude tubal occlusion in low-risk women, tubal patency tests like hysterosalpingography (HSG) or hysterosalpingo-contrast ultrasonography are reliable. Women with conditions such as previous pelvic inflammatory disease or endometriosis should undergo laparoscopy for diagnosis and treatment. Chlamydia trachomatis screening and appropriate antibiotic cover are recommended to prevent infection and women with blocked or dilated tubes (hydrosalpinges) should receive counselling on surgical options.

Women who are concerned about delayed conception should be tested for Rubella immunity and have their cervical smear history reviewed to prevent delays in fertility treatment if necessary.

If you would like to book a consultation with Miss Doncheva, do not hesitate to do so by visiting her Top Doctors profile today.

References:

Fertility-problems-assessment-and-treatment-pdf-35109634660549 (nice.org.uk)

Infertility (who.int)

Infertility - NHS (www.nhs.uk)

HFEA: UK fertility regulator