Guide to Understanding Infertility

In a nutshell

• It's a struggle that many face. In fact, 1 in 6 Australian couples struggle to get pregnant after a year of trying.
• Discussions around fertility and infertility often centre around the woman. When in fact around 40% of the time, the reason couples may struggle with infertility are due to solely male factors.
• For women there are a bunch of reasons why she might be struggling to conceive including the number and quality of her eggs, the ability to time ovulation, blocked fallopian tubes, a hostile uterus and common reproductive issues such as Endo, PCOS and Fibroids.
• For men's fertility it's all about the sperm. Issues can be caused by the sperm delivery, semen volume and sperm count and quality.
• It's really important to check-in on your fertility, particularly when you're trying to fall pregnant and are having no luck typically after 12 months of regular unprotected sex (if you're over 35, we recommend 6 months).
• Having a chat with your doctor or fertility specialist when you're struggling to conceive will help you decide on whether or not treatment options should be part of your fertility journey, and which one is best.
• Infertility issues can really take their toll. Just remember to not judge yourself too harshly and seek support from your loved ones or a professional when you need it.

It’s more common than you think

In our teenage years, we're taught about the importance of contraception to prevent pregnancy and STIs.

At that stage of our lives, we assume that once we stop using contraception we will be able to fall pregnant.

But the truth is: for some women, falling pregnant can actually be really freaking hard.

You could be following every rule in the "fertility bible", listening to all the right health advice, and having sex on a strict schedule. But nothing works.

If that’s you, know that you’re not alone. In Australia, 1 in 6 couples struggle to get pregnant after a year of trying. Sometimes, it just takes time.

Infertility doesn’t mean you’re infertile

We're very aware of the stigma attached to infertility and the clinical, isolating, and outright demoralising terms that can be used to describe women or couples going through it. It hurts.

Medically speaking, the term "infertility" is used to define couples who have not conceived after around 12 months of regular unprotected sex.

It doesn't necessarily mean that you will never be able to physically have children.

Like most problems or struggles in life, the first thing you need to do is understand what might be causing the difficulty, and finding a way to treat that.

Usually a discussion with your doctor can help with this. When you seek this information out, hopefully you will feel more confident that you're giving yourself the best chance of conceiving naturally.

What does it take to conceive naturally?

To conceive naturally, the same process applies every single time. That won't change. So it's a good idea to go back to the basics of what this actually looks like.

If anything, knowing the basics is going to help you navigate through any medical jargon that inevitably comes your way.

Conceiving naturally calls for your reproductive system to carry out a series of steps:

1. A healthy egg needs to be released (i.e. ovulated).
2. That egg needs to navigate its way to an open and healthy fallopian tube.
3. One strong sperm swimmer needs to reach this egg in time and break through the egg’s outer layer to fertilise it.
4. The egg needs to develop into an embryo, which then attaches itself to the lining of the uterus.
5. The uterus has to be able to receive it and provide the nutrients needed for the embryo to develop into a baby.

If any of those steps are missing or something gets in the way of these steps happening, it could be tricky to get pregnant.

It takes two to tango

Conception is a recipe that calls for two core ingredients. An egg and a sperm. That makes the male the other half of the equation.

Basic details I know.

But crazy to think that fertility is often exclusively discussed in the context of a woman's only issue.

When in fact, around 40% of the time, the reason couples may struggle with infertility are due to solely male factors.

And, 40% of the cases are due to female factors and the remaining 20% are a combination or unexplained infertility.

What might be causing difficulties for the woman?

For the ladies, here are some reasons why falling pregnant could be taking longer than usual.

The number and quality eggs

Seeing as an egg is a core ingredient to achieving a pregnancy, the number of eggs you have and the quality of them is crucial.

The more healthy eggs you have, the better the chances that the egg that you ovulate is a healthy one.

Unfortunately our eggs are not like wine. As we age, so do they.

Ageing eggs have a harder time implanting in the uterus, which can lead to higher rates of miscarriage.

Other factors affecting the eggs include smoking and pelvic inflammation which can reduce the quality of your eggs too.

As age impacts quality, it also impacts the number of eggs we have.

Each year you turn one year older, your egg stash declines, reaching approximately zero by the time we reach menopause.

In Australia, the average menopause age is 51. However, the age you reach menopause varies a lot depending on factors like ethnicity, genetic factors and smoking.  

Ovulation and timing

I'm sure you'd know by now that your eggs aren't just realised willy-nilly. So even if you have unprotected sex, you're not going to get pregnant if there is no ovulated egg for the sperm to fertilise.

That's where timing comes into it.

Timing sex around your fertile window helps to optimise your chances of getting pregnant. And, that fertile window timing is around 5 days before you ovulate and the day of ovulation (when your eggs are released).  

Around 25% cases with infertility is due to not being able to time sex around ovulation properly.

Some women may not be ovulating at all, which makes it unlikely to conceive naturally. For others, ovulation might be irregular which is hard to predict or track when you are going to ovulate to time sex.

Occasionally, changes in lifestyle factors like increased stress, excessive weight gain or loss and excessive exercise can cause irregular ovulation.

Blocked tubes

Your fallopian tubes are muscular tubes that guide your egg from the ovaries down to the uterus. They are also where sperm travels to meet the egg in the uterus.

When the fallopian tubes are blocked or damaged, this makes it impossible for the ovulated egg to unite with the sperm to be fertilised.

Blockages may arise as a result of scarring due to infection or previous abdominal surgery.

Pelvic inflammatory disease (PID) due to sexually transmitted diseases such as chlamydia or gonorrhoea is the main cause of fertility issues related to the fallopian tube.

A hostile uterus

Your uterus becomes quite the hostile environment when it's dealing with some issues. While it's not medically correct terminology, it's something that gets thrown around a lot.

Having a hostile uterus means it doesn't have enough cervical mucus or the right acidity for sperm to swim through it.

Most forms of contraception have this effect on your cervical mucus to make it a hostile environment to prevent pregnancy.

So, how does this happen when you're not on contraception?

Well, many reasons. The good news is that most of the causes are treatable and in your control to change!

This includes dehydration (drink more water), bacterial vaginosis and pelvic inflammatory disease (your doc could prescribe some antibiotics for those two).

Ironically, some medications that are used to treat fertility (like Clomid) can dry out the mucus.

Common reproductive conditions

Polycystic Ovary Syndrome (PCOS), Endometriosis and Fibroids are the most common conditions that may cause couples to have difficulties getting pregnant.

But having these conditions doesn't automatically give you a life-long infertility sentence. It can make it harder though.  

What’s important is that you talk to a doctor who understands the condition. By getting diagnosed early if you have it, you can work with your doctor to manage and treat it, giving you a better chance to conceive.

PCOS

PCOS is a condition where your reproductive hormones, more specifically, androgens (male sex hormones; like testosterone and DHEA) are out of balance. This imbalance interferes with ovulation, making it tricker to fall pregnant.

While PCOS is common, estimated to affect 1 in 10 women in Australia, it’s also the most treatable cause of fertility issues. There are things in your control to kickstart your ovulation.

Symptoms of PCOS include irregular or lack of ovulation or periods, acne and/or oily skin, excessive body hair, weight gain or balding.

If you’re curious to read more, take a squiz at our PCOS guide.

Endometriosis

Endometriosis is a condition where the lining (known as endometrial tissue) grows outside your uterus.

When that lining tries to break down during a period, unlike your actual period, it has no outlet to be carried out of the body because it’s not in the uterus.

The result? Awful stabbing pains, inflammation and potential scarring in your ovaries, pelvis, bowel and/or bladder.

If you're trying to conceive, Endo causes a number of issues:

• It can cause scar tissue to develop, which can damage the ovaries or block the fallopian tubes.
• Inflammation caused by Endo can reduce egg quality and make the uterus a hostile environment for sperm to do its thing.

To actually diagnose and treat Endo, women need to undergo a small surgery procedure known as a laparoscopy.

You should have a conversation with your doctor if you are experiencing any of these symptoms that can be caused by Endo: painful periods, pain during sex or bowel movements, heavy and long periods or chronic fatigue.

If you suspect you may have it or you want to learn more, read our Endometriosis guide.

Fibroids

Fibroids are a growth in your uterus, and around 40% of women have had them before.

Having fibroids doesn't always mean this will impact your fertility, or be the sole reason why you may be struggling to fall pregnant, or stay pregnant.

It all depends on where they are, and how big.

However, fibroids can cause issues.

• They can change the shape of the cervix, which affects the number of sperm that can enter.
• They can also change the shape of the uterus, which can interfere with the movement of the sperm or embryo.
• Fibroids can also block the Fallopian tubes.

Depending on the size and location of the fibroids, you might experience no symptoms, or you could experience long, heavy periods, irregular periods, pain or pressure in the pelvis, frequent urination and constipation.

What might be causing difficulties for the man?

When it comes to male fertility, the focus is on the sperm and making sure it has a safe (and efficient) journey to the egg.

So, when it comes to what might be causing difficulties for the male, the most common things to check up on are things that impact how the sperm is feeling and what the journey looks like for it.  

Sperm delivery

For sperm to arrive to the party, it needs to be ejaculated.  

Anything that gets in the way of a man being able to do that can make it more difficult to conceive naturally.

We're talking things like:

• Being able to keep it up long enough to ejaculate.
• Painful sex or psychological issues that might interfere with finishing.
• Blockages in the tubes that carry the sperm.

Sometimes, semen can lose its way during an orgasm. Instead of leaving via the penis, it finds another way and enters the bladder. Also known as retrograde ejaculation.

Semen volume

The more semen, the better. The seminal fluid makes it a cruisy ride for the sperm to enter the woman.

Sperm count

Just like women count their eggs, males count their sperm. Why? Because the number of individual sperm helps with fertility.

After all, they have to swim a mighty long journey to get to the egg. Only the fittest will survive and not all sperm that start the race will finish it.

So, the more sperm you have to begin with the more chances you have.

While studies aren't yet clear, another common condition that is thought to lower the sperm count and affect sperm quality is called Varicoceles.

Varicoceles is a common condition that causes swelling of the veins in the testicle, but it's also entirely reversible.

Despite it being one of the most common causes of male infertility, studies aren’t yet clear how having a varicocele impacts fertility.

But experts believe that it is at least partly due to the warm blood pooling in the varicocele, raising the temperature in the scrotum.

Sperm quality

The quality of the sperm is typically determined by its motility and morphology (i.e the way it moves and the way it looks).

Sperm motility - the way it moves.

Once the sperm get to the starting line of the cervix, they're on their own.

They have to swim quickly through the female reproductive tract and reach the egg, in order to have a chance to fertilise it. It’s a long journey to the egg, so you need strong swimmers.

Sperm morphology - the way it looks.

This refers to the shape and size of the sperm. Who knew that sperm had an ideal look?!

The ideal sperm looks like:

• Around three micrometers-wide
• An oval head
• An uncoiled tail

This matters because sperm need to be a certain shape to have the best chance of penetrating an egg.

This doesn’t mean abnormally shaped sperm can’t fertilise the egg, it just makes it harder.

Health issues and lifestyle factors can play a significant contributing role to the sperm count and quality.

There are simple ways to boost male fertility that you can check out in our Male Fertility and Lifestyle Guide.

Getting a fertility check up

Speaking to your doctor to understand what's going on is a must.

You'll know what you can do to improve your chances and understand what treatment you might need to go through.

When should you check in with your doctor?

Generally, if you and your partner have been trying with regular unprotected sex for 12 months without any luck, then it's time to chat.

Or, if you're over 35 years old, you should consider checking in with a fertility specialist after 6 months of trying.

What can I expect during a check up?

Your doctor will most likely take a hormone blood test and transvaginal ultrasound (yes, inside your vagina) in order to assess what’s going on.

Once they have more information about what's going on in your body, they can tell you what the next steps are.

Just remember, around 40% of fertility challenges are due to male factors, so it’s also worth running a sperm test for a male partner, if they are involved too.

Know your options

The ways in which families are created today are all varied. Given that, this means there are a number of treatment options to help many types of fertility scenarios.

The main thing is that you get your doctor to walk you through the treatment options that are going to be suitable for you. When you know this, you'll be another step closer to finding out the underlying reason you might be having issues falling pregnant in the first place.  

There are several treatment options available.

Note: The effectiveness of each treatment depends on what's causing the issue:
Grey icons indicate what difficulties the treatment helps with.
Purple icons indicate the elements that need to be present for the treatment to be most effective.  

Ovarian Stimulation

Ovulation stimulation is taken in the form of an oral or injectable hormone medication. It's designed to wake up your ovaries and help your body regulate ovulation.  

While you're taking the medication, a doctor will monitor you through your cycle using ultrasound and blood tests.

They do this so that they can give you a heads up on when you should be having regular sex to maximise your chance of pregnancy.

Intrauterine Insemination (IUI)

IUI involves sperm being placed directly inside the uterus with the help of a doctor.

The procedure puts the sperm directly into the uterus, so that it can start its journey closer to the egg and have a better chance of fertilising it. This gives the sperm a head start, but it still requires a sperm to reach and fertilise the egg on its own.

In Vitro Fertilisation (IVF)

IVF is the process of taking the egg and sperm out of your body and giving them a little nudge together in a lab, culturing the fertilised egg, and then transferring the embryo back into a woman’s uterus.

It involves using injectable hormones that will stimulate the ovaries to produce as many mature eggs as safely possible.

The eggs are then retrieved by inserting a thin needle through your vagina, under sedation.

The eggs are then combined with the sperm in the lab. The goal here is to produce high quality fertilised eggs which at this point can be referred to as embryos.

Only one of these embryos are then transferred into the uterus to grow into a baby!

Intracytoplasmic Sperm Injection (ICSI)

ICSI is an additional part of an IVF treatment cycle. It's where a single sperm is injected into a single egg to assist with the fertilisation.

In this procedure, a single sperm is given the upper hand by getting directly injected into the egg to fertilise it, skipping the entire swimming and need to penetrate the outer layer of the egg.

Donor sperm, eggs or embryos

Donor sperm, eggs or embryos can be used for couples where their own sperm and/or egg can’t be used (or chosen not to be used).

For couples having trouble conceiving naturally with their own egg or sperm, a donor can donate theirs.

• If using donated sperm, you’ll go through the IUI or IVF procedure.
• If using donated eggs or embryos, you’ll go through IVF procedure.

You got this

The journey to conceiving can feel like forever to some. And, at times, it can feel like nothing is in your control.

It can be especially hard on the days where the sight of kids at the park can really bring you down.

Or attending a friend's baby shower is the last thing you want to do.

On days like these, take extra care of your mental and emotional health (easier said than done, we know) and get support.

Try to not judge yourself too harshly, because you are allowed to feel these emotions.

But if it does get a bit too much to handle, make sure you speak with someone who can listen to you and help you - whether that's your partner, your family, your friends or a professional.

And don’t lose sight of the things that are in your control. It's the choices you make in the process of maximising your chances of getting pregnant.  

Arm yourself with the right information so that you go into any appointment feeling confident and prepped with the right questions. That way you'll know you are making informed decisions that are right for you.