13 Ways to Know Why You Are Infertile with Expert Advice on Treatment

By: Dr. Azuka Ezeike, MBBS, FWACS (Obstetrics and Gynaecology), FMCOG, MSc (Public Health). Medically reviewed by: Dr. Tii Ngwachi Munghieng, MD

 

A happy Africa couple in colourful top wear

 

Highlights

• Infertility is the inability to conceive after 12 months of regular unprotected sexual intercourse

• It affects 17.5% of adults worldwide and about 13% of Africans

• Diagnosis involves includes medical history, physical examination, and targeted tests for both partners

• Lifestyle modifications like a healthy diet, weight loss, and stress management can improve fertility

• Treatment options range from medications and surgeries to advanced techniques like In-vitro fertilisation (IVF)

• Counseling and community support play vital roles in managing infertility's emotional impact.

 

Introduction

Understanding Infertility

Infertility is associated with societal pressure and stigma, often leading to desperate attempts to identify the cause and seek treatment. In African society, it is not uncommon to encounter loudspeakers blaring from cars parked in open streets, inviting people to purchase drugs that claim to treat all kinds of diseases, including infertility. Unfortunately, the field of infertility treatment is plagued with quackery, and many individuals have fallen victim to quacks in their quest to conceive.

The World Health Organization (WHO) defines infertility as a disease of the male or female reproductive system characterised by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse.

When a couple faces infertility, they often blame each other. This is largely due to misconceptions. This can lead to inappropriate treatments and, in some cases, delays in receiving effective care. Therefore, understanding the actual causes of infertility and the available treatment options is crucial.

The article provides you with factual information on how the different causes of infertility are diagnosed and the treatment options.

What are the Types of Infertility and Who is Affected?

Infertility can either be primary, when a person has never achieved pregnancy or secondary when pregnancy has once occurred.

It affects one in six people in their lifetime accounting for about 17.5% of the world's adult population. Infertility is a global threat as it affects people all over the world.  It affects about 13% of people in Africa

1 in 8 people (13%) in sub-Sharan Africa have been affected by infertility in their lifetime. Source (p. 13)

 

Click here to learn more about the types and causes of infertility.

 

How is Infertility Diagnosed?

To diagnose infertility, you need to visit the hospital with your spouse or partner for a thorough check. It is recommended that a couple should be checked if they are yet to conceive after 12 months of having regular unprotected sex. [1] Women above 35 years and those with known causes of infertility, e.g., Polycystic ovarian syndrome (PCOS) should be checked after 6 months. [1] 

At the clinic, your doctor would do the following:

• Ask you and your spouse or partner some important questions (History) 
• Check you and your spouse or partner (Physical examination)
• Perform necessary tests on both of you (Investigation).

History

Your doctor will take a history from both of you. The history would involve questions on:

• The regularity and timing of sex
• The pattern of the menses
• Presence of signs of ovulation(release of eggs) 
• Previous history of sexually transmitted infection in both of you
• Previous history of  reproductive organ surgeries in both of you
• History of chronic illnesses like diabetes
• History of discharge of milk from the breast
• History of any growth on any part of the body
• History of drug abuse

Examination

The examination would involve:

• General examination
• Specific examination of the reproductive organs like the womb, the cervix and vagina, the testes, etc.
• Examination of other relevant organs like the thyroid gland and the breast

Investigations (tests)

Investigations are directed at assessing the function of your reproductive organs. It is done for both you and your husband.

It involves tests to check:

• Sperm production by the testes
• Egg production by the ovary 
• The state of the womb
• The state of the fallopian tubes
• The state of the pelvis
• The state of the cervix and vagina

Tests to Know Why You are Infertile

There are many tests available for the assessment of infertility in couples and not all of them need to be performed before a healthcare provider or gynaecologist can establish the cause of infertility.

The tests include the following:.

A. Tests for the Man

1. Semen analysis

Semen analysis is a crucial test for the man. Your husband submits his semen to the laboratory and this is used to assess the count, shape and movement of the sperm.

The normal values are:

• Sperm count of greater than 15 million/ml or up to 39 million per ejaculate
• 40% of motile(mobile) sperms 
• At least 4% with normal shape

Reduced sperm count is referred to as oligospermia. When the sperm count is zero, it is referred to as azoospermia. 

If the semen analysis is abnormal, other tests to be done include:

2. Hormonal tests

Test for hormone levels like follicle-stimulating hormone (FSH), Luitenising hormone (LH), testosterone, prolactin and thyroid hormones. This test detects problems in the hypothalamus, pituitary gland and thyroid gland 

3. Ultrasound of the testes and the pelvic organs

This is used to check the size and structure of the testis and also check if the veins inside the scrotum are enlarged.

4. Vasography

This is a type of X-ray used to test for blockages in the vas deferens and the ejaculatory duct. These are the tubes that carry sperm from the testis to the penis.

Diagnostic evaluation for infertility. Click on image to enlarge

 

B. Tests for the Woman

Test for Ovulation (Release of eggs)

During the ovulation period, there is a slight rise in body temperature. In addition, you may experience pain in your lower abdomen and may have stretchy gel-like vaginal discharge that looks like egg-white. [2]

Ovulation problems are assessed using the following: [2]

5. Home ovulation prediction kits 

These are urine tests that detect if ovulation has occurred. It detects the presence of Luteinising hormone (LH) in the urine.

6. Hormonal tests

• These are blood tests for progesterone, a hormone produced by the ovary after ovulation.  This is usually done in the middle of the second half of the menstrual cycle. 
• Evaluation of the LH, FSH. Prolactin and Testosterone also help to assess for PCOS and other causes of lack of ovulation.
• Thyroid hormone levels can also be checked if there is a suspicion of thyroid problems.
• Antimullerian hormone: This is a blood test used to access the ovarian reserve(number of eggs left in the ovary) This is not a routine test but is very useful for patients being prepared for ovulation induction for In-vitro fertilization (IVF)

7. Follicular tracking 

This is the use of ultrasound to track the development of eggs by the ovaries.

Assessment of the Fallopian Tubes

This involves the assessment of the patency (opening) of the fallopian tube. 

The tests include

8. Hysterosalpingogram (HSG)

This is the x-ray of the womb and fallopian tubes during the introduction of a special dye into the womb via the cervix. It shows whether the tubes are open or not. It can also show whether there are adhesions (scar formation) or fibroids inside the womb. [3]

 9. Hysterosalpingo Contrast Sonography (HyCoSy)  

The HyCoSy test is is similar to the HSG except that a high frequency sound device (ultrasound machine) is used instead of the X-ray machine to assess the state of the womb and tubes. It is an alternative to HSG. It is a less painful procedure and does not involve radiation exposure.

Both HSG and HyCoSy also evaluate the state of the womb cavity as well.

10. Laparoscopy and dye test

This is a form of operation that is used to check if your tubes are open. It involves the visualisation of the pelvic organs through cameras at the end of a special tube that is inserted through tiny holes in your abdomen. It involves injecting a dye (methylene blue) through your cervix and watching for the release of the dye from the tubes.

The procedure is also used to assess the state of the outer surface of the womb, the ovaries and the pelvis.

Assessment of the womb (uterus) and pelvis

Problems in the womb are evaluated using:

11. Ultrasound of the pelvis

This detects problems like fibroids, polyps (growth inside the womb cavity) and endometriosis (when the lining of the womb is implanted outside the womb). This is usually done through the vagina (transvaginal ultrasound) but can also be done through your abdomen (transabdominal ultras

12. Hysteroscopy

This is a procedure that involves the visualisation of the state of the cavity of the womb with a camera.

13. Saline infusion sonography

This is an ultrasound procedure that involves the visualisation of the cavity of the womb by injecting normal saline (a type of drip)

The womb cavity can also be assessed with HSG and HyCoSy. Likewise, the outside of the womb can also be checked with laparoscopy.

 

Treatment of infertility

1. Lifestyle changes

Some lifestyle changes can increase your chances of getting pregnant. These can improve the production of eggs and sperm by the ovary and testis respectively. [4] 

These include:

• Moderate exercise 
• Healthy diet
• Weight loss 
• Stress management
• Avoiding excessive alcohol intake
• Avoiding smoking and illicit drug abuse
• Avoidance of environmental toxins that can increase the risk of infertility

 

2. Medical treatment

 In women

• Medications for hormonal problems like hyperprolactinaemia(high prolactin level) and thyroid problems
• Medications to help your ovaries to produce eggs in women, e.g., clomiphene citrate, letrozole

In men

There are limited options for the medical treatment of infertility in men. 

Medications like Human chorionic gonadotrophin (HCG), Human menopausal gonadotrophin (HMG), clomiphene citrate, anastrozole and bromocriptine may be used in selected cases.

Use of fertility supplements

Many fertility supplements are marketed under various brand names. Most however do not have any scientifically proven efficacy and excessive intake of some may even be harmful. [5]

Folic acid is the only recommended supplement for women intending to conceive. It helps to prevent birth defects in the brain and spinal cord.

 

3. Surgical treatment

Some causes of infertility require surgical operation and there are a variety of surgical options that may improve fertility. [6]

In women

Surgeries that may help improve fertility include:

• Myomectomy(removal) of fibroids 
• Adhesiolysis (removal of adhesions from the womb and pelvis 
• Removal of endometriosis deposits
• Ovarian drilling in PCOS patients. This involves the drilling of holes in both ovaries. This helps to improve ovulation

Since the advent of IVF, surgeries to correct blockage of the fallopian tube are rarely done.

In men

Some surgical procedures that may improve fertility in men include:

• Varicocelectomy: tying of the enlarged veins in the scrotum
• Vasotomy: removal of blockages in the vas deferens

 

4. Assisted Reproductive Technologies (ART)

Assisted reproductive technology is used in patients in whom medical and surgical treatments are not possible or have failed. [7]

• It involves retrieving the egg from the woman and fertilising it with a sperm outside the body (in vitro fertilization). The fertilised egg (embryo) is subsequently transferred back to the womb for implantation. This is known as in-vitro fertilisation and embryo transfer. (IVF-ET)
• The egg and sperm may be either retrieved from the couple or donors depending on the circumstances.
• Artificial insemination:  This is when sperm is injected into the womb to improve the chances of pregnancy. It is not usually considered to be an ART procedure since the eggs are not manipulated outside the body.

 

 5. Support and counselling

Infertility is a very emotional journey for the couple. Therefore, emotional and psychological support should be provided by the health practitioners, families and community. Evidence shows that this is associated with some reduction in distress and increases the chances of conception. [8]

 

Conclusion

The journey of infertility can be challenging for any couple. In most cases, the cause can be linked to either the male, the female, or both partners. Sometimes, no specific cause is found. Fortunately, there are many ways to manage infertility, and new treatment options are continually emerging. Understanding the possible causes and knowing that solutions exist can offer hope to those affected. It also helps reduce the stigma and societal pressure often associated with infertility.

 

References

1. Carson SA, Kallen AN. Diagnosis and management of infertility. JAMA. 2021;326(1):65–76. doi: 10.1001/jama.2021.4788. Available from here.

2. Su H, Yi Y, Wei T, Chang T, Cheng C. Detection of ovulation, a review of currently available methods. Bioeng Transl Med  2017;2(3):238–46. doi: 10.1002/btm2.10058. Available from here.

3. Cue L, Mayer C, Martingano DJ. Hysterosalpingogram. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Last update 2024 May 6. [Cited Dec. 9, 2024].Available from here

4. Kim EJ, Nho JH. Lifestyle interventions for adults with infertility. J Lifestyle Med. 2022 May 31;12(2):69–71. doi: 10.15280/jlm.2022.12.2.69. Available from here

5. Tulandi T. The Evolution of Surgery for Infertility.Journal of Obstetrics and Gynaecology Canada , Volume 41, S327 - S329. doi: 10.1016j.jogc.2019.08.019. Available from here

6. Skoracka K, Ratajczak AE, Rychter AM, Dobrowolska A, Krela-Ka?mierczak I. Female fertility and the nutritional approach: the most essential aspects. Adv Nutr [Internet]. 2021 Jun 17;12(6):2372–86. doi: 10.1093/advances/nmab068. Available from here.

7. Jain M, Singh M. Assisted reproductive technology (Art) techniques. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Last update June 7, 2023. [Cited 2024 Dec 9]. Available from here. 

8. Dube L, Bright K, Hayden KA, Gordon JL. Efficacy of psychological interventions for mental health and pregnancy rates among individuals with infertility: a systematic review and meta-analysis. Hum Reprod Update. 2023 Jan 5;29(1):71–94. Available from here.

  

 

Related.

Infertility: Causes in African Women and Men with Prevention Tips

Infertility in African Women: All You Need to Know

10 Common Hormone-Linked Disorders in African Women

Common Gynaecological Cancers in African Women

 

 

Published: December 16, 2024

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