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 protection, we'll automatically be able to fall pregnant.
But the truth is that for some women, falling pregnant can be really 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 — yet, for some reason, nothing works.
If that’s you, you’re not alone. In Australia, about 1 in 6 couples struggle to get pregnant after a year of trying [1]. Sometimes, it just takes time.
In this article, we do a deep dive into the topic of infertility, why it might happen and what you can do to overcome it. But first, let's debunk a common myth.
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 [2]. It doesn't necessarily mean that you will never be able to physically have children.
As with most struggles in life, it's important to understand what might be causing the infertility to then find a way to overcome it.
Usually a discussion with your doctor can help with this. Once you seek this information out, hopefully, you will feel more confident that you're giving yourself the best chance of getting pregnant naturally. Speaking of...
What does it take to conceive naturally?
Conceiving naturally calls for your reproductive system to carry out a series of steps:
- A healthy egg needs to be released (i.e. ovulated).
- That egg needs to navigate its way to an open and healthy fallopian tube.
- One strong sperm needs to reach this egg in time and break through its outer layer to fertilise it.
- The egg needs to develop into an embryo, which then attaches itself to the lining of the uterus.
- The uterus has to be able to receive the embryo and provide the nutrients needed for it to develop into a baby.
If any of those steps are missing or something gets in the way of them happening, it could be tricky to get pregnant.
It takes two to tango
Conception is a recipe that calls for 2 core ingredients: an egg and a sperm. That makes the male the other half of the equation.
It's crazy to think that fertility is often exclusively discussed in the context of a woman's issue, when in fact [3]:
- Around 40% of the time, the reason couples may struggle with infertility is due to male factors
- 40% of the cases are due to female factors
- The remaining 20% are a combination or unexplained infertility.
That's why in today's comprehensive guide, we'll touch on male and female infertility. Let's start with the ladies.
What are the most common causes of female infertility?
Looking at the female reproductive system, there are 5 common reasons why falling pregnant could take longer than predicted:
1. The number and quality of eggs
The more healthy eggs you have, the better the chances that the egg 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 like smoking and pelvic inflammation 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 1 year older, your egg stash declines, reaching approximately 0 by the time you reach menopause [4].
2. Ovulation and timing
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 in.
Timing sex around your fertile window helps to optimise your chances of conception. This fertile window timing is around 5 days before you ovulate, as well as the day of ovulation (when your eggs are released).
This can hard to track by yourself, which is why we recommend you use ovulation tests. These handy tests work by detecting your levels of luteinizing hormone (LH) — a positive result indicates high LH levels which means that an egg has been released and ovulation will occur within a few days [5].
Timing and ovulation are, indeed, two big factors and around 25% of cases of infertility are due to not being able to time sex around ovulation properly [6].
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 also cause irregular ovulation.
3. 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 these tubes are blocked or damaged — which may happen as a result of scarring due to infection or previous abdominal surgery — it makes it impossible for the ovulated egg to unite with the sperm and be fertilised.
Additionally, pelvic inflammatory disease (PID) due to sexually transmitted infections (STIs) such as chlamydia or gonorrhoea is the main cause of fertility issues related to the fallopian tube [7].
4. A hostile uterus
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, but how does this happen when you're not on contraception?
Well, there are many explanations for it, but the good news is that most of the causes are treatable and in your control to change.
This includes dehydration — in which case you should, you guessed it, drink more water — and bacterial vaginosis and PID, for which your doctor may prescribe antibiotics.
Ironically, some medications that are used to treat infertility (like Clomid) can dry out the mucus. If you experience this, consider speaking with your doctor.
5. Common reproductive conditions
Polycystic ovary syndrome (PCOS), endometriosis and uterine fibroids are the most common conditions that may cause couples to have difficulties getting pregnant (although none automatically gives you a life-long infertility sentence).
What’s important is that you talk to a doctor who understands the condition. By getting an early diagnosis, 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 trickier 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 problems [8].
Symptoms of PCOS include irregular or lack of ovulation or periods, acne and/or oily skin, excessive body hair, weight gain or balding.
Endometriosis
Endometriosis is a condition where 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 can cause scar tissue to develop, which can damage the ovaries or block the fallopian tubes. It can also lead to inflammation, which can reduce egg quality and make the uterus a hostile environment.
You should have a conversation with your doctor if you're experiencing any endometriosis symptoms, including painful periods, pain during sex or bowel movements, heavy and long periods or chronic fatigue. They'll help you get a diagnosis and if needed, treat your endometriosis.
Uterine fibroids
Fibroids are growths in your uterus, and approximately 40-80% of women have them [9].
Fibroids don't always affect fertility and they're not always the sole reason why you may be struggling to fall or stay pregnant. It all depends on where they are, and how big.
However, fibroids can:
- Change the shape of the cervix, which affects the number of sperm that can enter.
- Change the shape of the uterus, which can interfere with the movement of the sperm or embryo.
- 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 causes male infertility?
When it comes to male fertility, the focus is on the sperm and making sure it has a safe (and efficient) journey to the uterus and fallopian tubes.
So, it's important to check up on things that impact how the sperm is feeling and what the journey looks like for it. This includes:
1. 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, which is also known as retrograde ejaculation.
2. Semen volume
The more semen, the better. The seminal fluid makes it a cruisy ride for the sperm to enter the woman.
3. 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.
A common condition that is thought to lower sperm count and affect sperm quality is called varicoceles, which causes swelling of the veins in the testicle [10].
We should mention that studies aren’t yet clear how having a varicocele impacts fertility. However, experts believe that it is at least partly due to the warm blood pooling in the varicocele, raising the temperature in the scrotum.
The good news is that varicoceles are reversible, either through a catheter-directed embolisation or surgical ligation [10].
4. 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. 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. This refers to the shape and size of the sperm. The ideal sperm is around 3 micrometres wide and has an oval head and 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 also affect sperm production, count and quality. Luckily, there are simple ways to boost male fertility that you can check out in our Male Fertility and Lifestyle Guide.
The importance of testing your fertility
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 actively trying for a baby and having 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). Once they have more information about what's going on in your body, they can tell you what the next steps are.
Oh and 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.
What are the best fertility treatments?
There are several treatment options to help many types of fertility scenarios.
The most important thing is that you get your doctor to walk you through the 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.
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 and it is 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 is a fertility treatment where sperm is 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 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) and 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.
Finally, one of these embryos is 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, without the need to swim and 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 are chosen not to be used).
For couples having trouble conceiving naturally with their egg or sperm, a donor can donate theirs.
- If using donated sperm, you’ll go through an IUI or IVF procedure.
- If using donated eggs or embryos, you’ll go through an IVF procedure.
You got this
The journey to conceiving can often feel like forever and, at times, it can feel like nothing is in your control. Certain situations — like attending a friend's baby shower or seeing kids playing around in the park — can make things even harder.
When that happens, make sure to take extra care of your mental and emotional health (easier said than done, we know) and get the support you need. 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.
Image credit: Getty Images
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