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Fertility Guide

Everything you need to know about fertility. Discover the possible causes of infertility in both sexes and the different options for conceiving.  

Reviewed by Dr Sam Rodgers

17th March 2020

Contents

What is infertility?

Chapter 1

What is infertility?

What are the main causes of female infertility?

Chapter 2

What are the main causes of female infertility?

What are the main causes of male infertility?

Chapter 3

What are the main causes of male infertility?

How can I prepare myself for pregnancy?

Chapter 4

How can I prepare myself for pregnancy?

How is fertility investigated?

Chapter 5

How is fertility investigated?

What treatments can help me conceive?

Chapter 6

What treatments can help me conceive?

Top 10 common fertility myths

Chapter 7

Top 10 common fertility myths

Where can I get support?

Chapter 8

Where can I get support?

What is infertility?

Chapter 1

What is infertility?

Understand the different types of infertility and the statistics surrounding conception.

Infertility is when a couple can't get pregnant after 12 months or more of having regular unprotected sex. Infertility affects both men and women equally. There are two main types of infertility:

  1. Primary Infertility – where someone who has never been pregnant is struggling to conceive.
  2. Secondary Infertility – where someone has had one or more pregnancies in the past and is struggling to conceive again.

Fertility problems are not uncommon; and if you are struggling to conceive, be reassured that you are not alone. Around one in every seven couples may have difficulty in conceiving. However, the good news is that 80% of couples, who are having regular sex, will have successfully become pregnant within one year [1]. For couples that have been trying to conceive for three years or more, the likelihood of conceiving naturally reduces to 25% or less. However, it is essential to get help as early as you can. If you are under the age of 35 and you have to have been trying to get pregnant for at least one year without success, you can then see your doctor. If you're over the age of 35, then you need only to have been trying for six months before seeing your doctor. However, there is so much you can do while you're waiting for an appointment to optimise your ability to conceive naturally and you can read more about this in Chapter 4 'How can I prepare myself for pregnancy?'

What are the main causes of female infertility?

Chapter 2

What are the main causes of female infertility?

Struggling to conceive? Learn about what could be causing your infertility and how you can recognise its symptoms.

Several underlying conditions can cause female infertility. However, in 25% of cases, no cause for the fertility problem can be established. Below is a list of the most common reasons why you may be struggling to conceive:

  • Unexplained infertility
  • Thyroid condition
  • Polycystic Ovary Syndrome
  • Blocked fallopian tubes
  • Endometriosis
  • Uterine abnormalities
  • Premature Ovarian Insufficiency
  • Medication and drugs
  • Regularity of sex

Unexplained infertility:

Approximately 1 in 5 couples will are diagnosed with unexplained infertility. Unexplained infertility means doctors cannot find any known cause for your difficulty in conceiving. While it is reassuring to know that everything seems to be healthy, some couples find this diagnosis frustrating as there is nothing to 'fix' to improve their fertility. Some doctors believe that there is no such thing as unexplained infertility, and it is just that we don't yet have the technology to identify the problem. It is likely that as our knowledge increases and our techniques and treatments improve, the diagnosis of unexplained infertility will become less and less frequent.

The majority of couples with unexplained infertility, who don't go on to conceive naturally, will be offered fertility treatments to help conception.

Thyroid conditions:

A thyroid disorder can make it difficult to conceive. Thyroid problems are common reasons why some women may find it difficult to conceive or indeed maintain a pregnancy. However, whether your thyroid is overactive or underactive, a thyroid disorder can be diagnosed and treated. The first step is recognising that you may have a thyroid problem and getting help. 

The thyroid is a small butterfly-shaped gland that partially surrounds your windpipe, and it is important for producing the hormones that are responsible for regulating your metabolism.

Symptoms of an underactive thyroid are:

  • Low body temperature
  • Tiredness
  • Weight gain
  • Slow pulse rate
  • Goitre (protruding thyroid)
  • Menstrual cycle disturbances – longer, heavier periods or absence of periods
  • Infertility or recurrent miscarriage
  • Low libido
  • Depression
  • Memory loss
  • Slow metabolism
  • Dry skin and hair
  • Hair loss

Symptoms of an overactive thyroid are:

  • Nervousness, anxiety and irritability
  • Mood swings
  • Difficulty sleeping
  • Tiredness and weakness
  • Menstrual disturbances – lighter, irregular periods.
  • Infertility
  • Sensitivity to heat
  • Swollen neck (goitre) from an enlarged thyroid gland
  • Irregular heartbeat or palpitations
  • Twitching or trembling
  • Weight loss

Women with a thyroid disorder find conceiving difficult because it disrupts their menstrual cycle and ovulation. Thyroid disorders are generally diagnosed by blood tests which measure your levels of circulating thyroid hormones and thyroid antibodies. You may be diagnosed with Hashimoto's Disease, an autoimmune condition which is the most common reason for an underactive thyroid. Hashimoto's is diagnosed by high levels of thyroid antibodies in a blood test.

If you are struggling to conceive, have had early miscarriages or notice the symptoms listed above, see your doctor for a discussion about whether you could have a thyroid problem. Your doctor can take a full thyroid function test to assess your thyroid levels, or you may wish to order a thyroid test to do at home. If necessary, your doctor can commence treatment to replace your thyroid hormones (or prevent you from overproducing thyroid hormones) and therefore help you to conceive.

Polycystic Ovary Syndrome (PCOS):

PCOS is a common hormonal condition among women of childbearing age. PCOS is very common, affecting up to 1 in 5 women. In women with PCOS, the egg follicles in the ovaries don't develop as they should; forming many tiny cysts which disappear only to be replaced by more cysts. PCOS is a chronic condition, and although the cysts are not dangerous and do not go on to form ovarian cancer or need surgical removal, they can impact on lots of areas of a woman's life, including her ability to get pregnant. Women with PCOS also have hormone imbalances which mean that their eggs don't mature properly and their periods can be erratic, making it difficult to pinpoint if or when ovulation occurred.

The good news is that many women with PCOS do go on to have successful pregnancies; it might just take a bit longer and need a bit more help from a doctor or fertility expert.

If you think you may have PCOS or want to understand more about your condition, you may like to have some blood tests taken. See our PCOS blood tests for more information on the tests required to help diagnose PCOS.

For more information about PCOS and what this may mean for your fertility, see the PCOS Guide.

Blocked fallopian tubes:

Blocked fallopian tubes are one of the common causes of infertility. The fallopian tubes play a crucial role in reproduction, as this is where egg and sperm meet for fertilisation. The fertilised embryo then travels down the fallopian tube to implant in the uterus. If your fallopian tubes are damaged or blocked, this can hinder the passage of the fertilised embryo, preventing it from successfully implanting in your womb. Previous infections such as chlamydia or gonorrhoea are the most common cause of tubal factor infertility as they can cause scarring.

It's not possible to know if you have blocked fallopian tubes as you won't have any symptoms. Having had a sexually transmitted infection in the past, or previous abdominal surgery, raises your risk, so if this applies to you, we recommend discussing it with your doctor. An ultrasound scan and investigative surgery can diagnose Tubal Factor Infertility.

Endometriosis:

According to the charity Endometriosis UK, 1 in 10 women have a diagnosis of endometriosis, and it can take up to 7 years for a woman to be diagnosed. A definitive diagnosis can often be confused for other conditions such as Irritable Bowel Syndrome (IBS). Endometriosis is a common cause of infertility among women.

Endometriosis means that the tissue similar to that of the lining of the womb grows in other places in the pelvis, including the bowel, ovary and fallopian tubes. It can cause a chronic inflammatory reaction and may lead to the formulation of scar tissue within the pelvis. Endometriosis is a long-term condition that can be painful and debilitating and can impact significantly on your life.

The symptoms of endometriosis can vary. Some women are severely affected, while others might not have any noticeable symptoms. Endometriosis may run in families.

The main symptoms of endometriosis are:

  • Abdominal or back pain
  • Pain in the legs and chest
  • Extremely painful periods
  • Pain during or after sex
  • Pain when urinating or opening your bowels
  • Nausea, constipation, diarrhoea and blood in the urine
  • Infertility
  • Chronic fatigue
  • Depression

Investigations and treatment for endometriosis are available, and many women go on to conceive successfully. To find out more, visit our blog post via the health hub. We recommend talking to your doctor if you are concerned about endometriosis.

Uterine Abnormalities:

Several uterine abnormalities can impact on fertility. Usually, a woman isn't aware of any problems until she is unsuccessful at trying to conceive naturally. Women between the ages of 30 and 50 are most likely to be affected by a uterine abnormality.

Fibroids are one of the most common abnormalities of the uterus and affect around 1 in 3 women. They are a non-cancerous growth that develops in or around the uterus. The growth is made up of muscle and fibrous tissue and can vary in size from being very small to very large.

1 in 3 women may experience symptoms such as:

  • Heavy or painful periods
  • Abdominal discomfort
  • Lower back pain
  • Frequency of urination
  • Constipation
  • Pain during sex

Small fibroids may not pose a problem for your fertility, but your doctor may recommend surgical removal of the fibroid if it is lying where an embryo would typically implant. It is more likely that a large fibroid will be removed surgically, although it is also possible to take medication to help shrink fibroids.

Another anatomical uterine abnormality is a Septate Uterus, which is where a wall of muscle down the centre splits the uterus into two. Sometimes the wall only comes part-way down the womb (sub-septate) and other times it comes the whole way down (septate). Women with sub-septate or septate wombs are more likely to have difficulties with conception. There is also an increased risk of early miscarriage and preterm birth. Other anatomical abnormalities of the uterus such as a bicornate, uni-cornate, arcuate or didelphic uterus are less likely to affect conception but can increase the risk of miscarriage and premature birth.

Premature Ovarian Insufficiency (POI):

POI is also known as premature or early menopause and is the term used when ovaries stop working earlier than usual. The average age for menopause is 55, but sadly, POI occurs in 1% of women under the age of 40 and can even affect women in their 20s and 30s too, however, this is rare.

It can take some time to be diagnosed with POI, especially if you are young; you may be diagnosed with other conditions that can cause your periods to stop, such as PCOS. A definitive diagnosis is obtained by a blood test to measure follicle-stimulating hormone (FSH) and then a repeat test four weeks later. High levels of FSH can indicate that your ovaries are not working as they should; however, FSH can be very changeable in the early stages of POI, which is why it is a difficult condition to diagnose.

In very young women (even teenagers), their periods may not start at all, while in other women, their periods may become irregular and eventually stop altogether.

Other symptoms of POI include:

  • Infertility
  • Hot flushes and night sweats
  • Insomnia and disturbed sleep
  • Palpitations
  • Weight gain (especially around the waist and abdomen)
  • Skin and hair changes (dryness, thinning)
  • Headaches
  • Breast tenderness
  • Mood swings and irritability
  • Anxiety/panic attacks
  • Loss of self-esteem
  • Lowered libido
  • Difficulty concentrating and memory lapses
  • Fatigue/low energy levels
  • Joint/muscle pain
  • Vaginal dryness and urinary infections
  • Depression

If you have a diagnosis of POI, then your best chance of conceiving might be with a donor egg and IVF. Finding out that you can't have a biological child can initially be very upsetting. The best thing is to take time to consider your options and what feels right for you and your partner. You can find out more about egg donation in Chapter 6 – 'What treatments will help me conceive?'

Medication and drugs:

The side effects of some types of medicines and drugs can negatively affect your fertility. If you are concerned about any medication you are taking, talk to your doctor but do not stop taking any prescribed medication until you have discussed this with your doctor.

The medication and drugs that may affect your fertility are:

  • Non-Steroidal anti-inflammatory drugs such as ibuprofen and aspirin. Long-term use or high doses may make it more difficult to conceive.
  • Chemotherapy can sometimes cause ovarian failure. In this situation, women who wish to have a family may be offered egg freezing before starting their chemotherapy treatment.
  • Neuroleptic medication used to treat psychosis can sometimes cause difficulty in conceiving.
  • Spironolactone, which is a treatment for conditions such as oedema and acne, can impact on fertility. However, this is generally reservable after stopping the medication. Women who are trying to conceive should not take spironolactone as this can have a severe effect on the developing baby.
  • Illegal drugs, such as marijuana and cocaine, can make ovulation and conception more difficult.

Infrequent sex

Infrequent sex is the number one reason why couples struggle to conceive! If you have regular sex every 2-3 days throughout the cycle, then you are more likely to conceive within the first 12 months. For more information on when you should be having sex and what you can do to increase your chances of conception, take a look at Chapter 4 – 'How can I prepare myself for pregnancy.'

What are the main causes of male infertility?

Chapter 3

What are the main causes of male infertility?

Recognise the possible causes of male infertility and how they affect the body.

In the UK, a quarter of fertility problems are due to factors which affect men. Several issues can cause male infertility, and the causes are not always obvious. What we do know is the following issues can cause male infertility:

  • Hypogonadism
  • Problems of the testes
  • Erectile Dysfunction
  • Varicoceles
  • Overheating of the testicles
  • Alcohol, smoking and drugs
  • Medication and drugs

Hypogonadism:

Hypogonadism means that you have low levels of the sex hormone testosterone. Hypogonadism appears to affect around 5 in 1000 men. Men require sufficient levels of testosterone for physical and psychological wellbeing. Low testosterone levels can also impact on fertility and lead to long term health risks. Low testosterone can be due to a problem with the testicles themselves, or due to disorders of the pituitary gland or hypothalamus which control hormone production.

Symptoms of hypogonadism can include:

  • Fatigue and lethargy
  • Depression, anxiety, irritability
  • Reduced sex drive, erectile dysfunction
  • Decreased need to shave
  • Reduced exercise tolerance and strength
  • Excessive sweating and night sweats
  • Poor concentration and/or memory
  • Infertility

If you are concerned that low testosterone may be a factor for you, speak with your doctor who will be able to investigate your concerns further. You may also like to check your testosterone levels yourself and can find more information here.

Treating hypogonadism is aimed at restoring the normal levels of testosterone to improve general wellbeing and fertility.

Problems with the testicles:

The testicles produce and store sperm. If they are damaged, it can impact on the quality of sperm. Issues with the testicles can range from a congenital problem (from birth) and undescended testes. Other things like trauma to the testes, illness or infection such as chlamydia, gonorrhoea or prostatitis (inflammation of the prostate gland), previous surgery to the testicles and hernia repairs may all cause problems with the testicles.

Your doctor will need to examine you to diagnose a problem with your testicles.  They may suggest that you have an ultrasound scan and referral to a specialist to determine whether a testicular problem is affecting your fertility.

Erectile dysfunction (ED):

ED, also known as impotence, is the failure to achieve an erection. It is a widespread concern, especially in men over the age of 40 and can impact on the ability to conceive. Stress, tiredness, or drinking too much alcohol can all contribute to episodes of ED. However, if it occurs frequently, there may be other underlying physical or emotional conditions.

Your doctor or your local sexual health clinic will be able to investigate you for any physical and emotional problems and, where necessary, may suggest a referral to a psychosexual counsellor. Treatment for ED depends on the cause but can be very successfully treated with medication if this is appropriate for you.

Varicocele:

A varicocele is a cluster of enlarged veins in the testicles, similar to varicose veins in the legs. Approximately 15% of infertile men are affected by a varicocele, and it is, therefore, a significant cause of male infertility. A varicocele inside the left testicle is more common that in the right and you may notice that one testicle is bigger than the other. You may or may not experience pain, and the testicle may feel like 'a bag of worms'. Varicocele is a common cause of abnormal sperm production, but it is easy to diagnose and treat.

If you suspect a varicocele, discuss this with your doctor who will examine you and, if necessary, refer for you for an ultrasound scan.

If you have a normal sperm count, then you may not require any treatment - just repeat testing every 2-3 years. If you have an abnormal sperm test surgery may be offered, which can improve the quality of your sperm significantly within 3-12 months [2].

Overheating of the testicles:

The testicles hang outside the body for a good reason; they need to be kept at a lower temperature than the rest of the body to allow for optimum sperm production. In some circumstances, a man's occupation or lifestyle can mean that the testicles are warmer than they should be, which can impact sperm quality.

If you work in a hot environment like a bakery or spend a long time sitting at work, then this may impact your sperm production. It may not be practical to change your working environment, but if you can keep your testicles cool where possible it will help to improve sperm quality. The main thing is to avoid wearing tight underwear or lycra training shorts for long periods as these hold your testicles close to your body where the temperature is warmer. Limit the time spent in hot baths and hot tubs.

Alcohol and drugs:

Drinking alcohol (especially heavy drinking), smoking, and using drugs such as marijuana or cocaine can have a significant impact on your fertility; keep alcohol to a minimum while trying to conceive and avoid binge drinking. Smoking and drug abuse can deplete healthy sperm and make it very hard to conceive. See Chapter 4 – 'How can I prepare myself for pregnancy', for more information on healthy conception lifestyle choices.

Medication and drugs:

Some medicines and drugs can affect your fertility. If you are taking prescribed medication, then it is essential not to stop before speaking with your doctor. Explain that you are trying to conceive and see if there are alternative treatments available. But you should never stop taking a prescribed medication without consulting your doctor first.

The medication and drugs that may affect your fertility are:

  • Chemotherapy, which can sometimes severely reduce sperm production.
  • Anabolic steroids can reduce sperm count and mobility and can also lead to hypogonadism. Protein Shakes have also been linked with poor sperm parameters.
  • Sulfasalazine, which is an anti-inflammatory often used to treat conditions such as Crohn's disease or rheumatoid arthritis, may temporarily impact sperm count while taking the treatment.
  • Drugs, like marijuana and cocaine, can affect sperm production.
  • Herbal remedies, such as root extract of the Chinese medicine herb Tripterygium wilfordii, can affect sperm production or reduce the size of your testicles.

How can I prepare myself for pregnancy?

Chapter 4

How can I prepare myself for pregnancy?

Learn about the lifestyle changes you can make to optimize your chances of conception.

If you are under the age of 35 and have been trying to conceive for 12 months, or if you are over 35 and have been trying for six months, you should see your doctor. Your doctor will be able to recommend some initial tests and, if necessary, refer you to a fertility specialist. You can find out more about how fertility is investigated in Chapter 5 – 'How is fertility investigated?'

However long you have been trying to conceive, there is a great deal you and your partner can do to learn about your fertility and to optimise your general health to improve your chances of getting pregnant. Let's take a look at some of them below:

Lifestyle factors:

Nutrition

Your lifestyle and the choices you and your partner make will have a considerable impact on your fertility. Having a healthy balanced diet is crucial, and good nutrition is the building block for sperm and egg health. Make sure that you have ample protein in your diet combined with fruit and vegetables. Leafy green vegetables are particularly beneficial for sperm and egg health. Try to keep your sugar and refined carbohydrates such as cakes, biscuits, crisps etc. low, and switch to whole-wheat or brown bread, pasta and rice.

Weight and exercise

If you or your partner are overweight, it may be more difficult to conceive, and it could take longer to become pregnant. Having a healthy BMI is important for good fertility (see Appendix 1 to work out your BMI using the BMI Calculator). Exercise is positive, not just for your weight, but also for your mood and energy levels. Aim to do a mixture of cardiovascular exercise and weight training, and plan for 150 minutes of exercise a week. You don't even have to exercise for long stretches at a time; short 10 -minute bursts are also beneficial and might be easier to fit into your day. And don't forget to stand up - staying on your feet uses more calories than sitting and is better for your long-term health.

Alcohol and Drugs

The Department of Health recommends that women should not drink any alcohol if they are planning to become pregnant, and men should drink no more than 14 units of alcohol per week. Excessive drinking (including binge drinking) can be damaging to healthy sperm production. Recreational drugs may also impact on your fertility, and it is advisable to avoid taking any drugs when trying to conceive.

Smoking

Smoking can have a considerable effect on both sperm and egg quality, and it is recommended that you don't smoke while trying to conceive. If you do smoke, it can be difficult to stop. However, your doctor can offer guidance or refer you to organisations to help you. We need more research into the effects of vaping on fertility, but it is sensible to avoid any unnecessary chemicals when trying to conceive.

More evidence is needed to fully understand the impact that drinking caffeine has on both sperm and egg quality. However, it is sensible to reduce your caffeine consumption of coffee, tea and fizzy drinks. Some believe that one caffeinated beverage a day is acceptable. Aim to increase your water consumption to 2-3 litres per day (more if you are exercising) and enjoy fruit or herbal tea as alternatives.

Toxins

Toxins and fertility do not mix well. Toxins are so prevalent in our everyday lives that it is impossible to avoid all of these substances altogether; however, you can try and reduce your toxin exposure to benefit your fertility.

Here are some quick and easy ways to reduce your exposure to toxins:

  1. Avoid plastics
  2. A toxin called BPA (Bisphenol A) is an ingredient in plastics such as water bottles, cling film, coated saucepans, plastic containers and even banknotes and receipts. BPA termed an endocrine disrupter (which means that it disrupts your hormones) and is linked to infertility and breast cancer. Instead of using plastic water bottles, purchase a BPA Free re-usable bottle or drink out of glass. Avoid using cling film for covering food, particularly when reheating food in the microwave. When you get home from the shops, remove any plastic wrapping from the foods you have bought. Store food in glass rather than using cling film or plastic containers.

  3. Buy organic
  4. The best way to reduce your exposure to toxins from fruit and vegetables is to buy organic. However, you can also buy fruit and vegetables that are in season from a local farmers market or grow your own. Always wash fruit and vegetables before you eat them.

  5. Consider your beauty products.

    Many beauty products such as body wash, shampoo, conditioner, perfume, nail varnish and cosmetics contain parabens and other toxins that can affect male and female fertility. On average, a woman uses 12 beauty products per day containing a staggering 168 different chemicals. It may not be feasible to change all your beauty products in one, but over time, try to buy more natural and fragrance-free products.

  6. Cleaning products and air fresheners

    Cleaning products can be full of harsh toxins; however, it is now very easy to purchase more natural alternatives. When using any cleaning products, wear gloves to avoid the chemicals touching your skin and use in a well-ventilated area. Air fresheners contain phthalates which are endocrine disrupters which can quickly get into your system through your nose. They go directly to the hypothalamus in your brain, which can impact your hormone balance. Avoid the use of spray air fresheners as well as plug-in diffusers. Keep your windows open and let your house or workplace breathe naturally.

Supplements

You may choose to consider how supplements may help improve your fertility. Women trying to conceive are advised to supplement with a daily dose of 400mcgs of Folic Acid, which reduces the risks of neuro-tube defects developing during the early weeks of the baby's development. The Department of Health also recommends that men and women take a Vitamin D supplement between September and March. The best source of Vitamin D is through sunshine, and therefore a supplement can help improve your Vitamin D reserve in the winter months. You may like to check your Vitamin D levels with our Vitamin D blood test.

Do not take Vitamin A supplements or any supplement that contains Vitamin A (retinol), as too much of this supplement could harm your baby. Always check the label of any supplements you choose to take and ask your doctor if you are unsure.

Some couples may require other supplements based on their current health and diet; this is especially the case if a man has poor sperm parameters. It may help you to take advice from your doctor, nutritionist or fertility expert to find the right supplements for you.

Get to know your menstrual cycle

Sometimes it can be hard to understand your menstrual cycle and be confident when your fertile period is. For women who don't have regular cycles or may not be ovulating, it can be even harder. Taking the time to learn about your cycles and what your body is telling you can reduce the time it can take for you to conceive.

Sometimes it can be hard to understand your menstrual cycle and be confident when your fertile period is. For women who don't have regular cycles or may not be ovulating, it can be even harder. Taking the time to learn about your cycles and what your body is telling you can reduce the time it can take for you to conceive.

Your menstrual cycle is when an egg develops and releases from the ovary. At the same time, the lining of the uterus thickens to prepare for a pregnancy. If the egg isn't fertilised or doesn't implant, the lining of the uterus sheds and you have your period.

When you are trying to get pregnant, it is essential to know the length of your menstrual cycle so that you can estimate when you are likely to be ovulating and therefore, fertile. Your menstrual cycle starts on the first day of your period and ends the day before your next period is due. The average length of the menstrual cycle is around 28 days, although many women have longer or shorter cycles which is entirely normal.

The first day of your period is known as day one of the cycle. When a woman has her period, multiple eggs start to develop in the ovary. The hormone oestrogen causes the lining of the uterus to thicken in preparation for a fertilised egg.

Whether your cycle is long or short, you will usually ovulate 10–16 days before the start of your next period, however, this can vary between women which is why identifying when you have ovulated is vital for the timing of intercourse. Ovulation triggers the production of progesterone which prepares the lining of the uterus for implantation. Your womb lining needs to be spongy, thick and full of nutrients so that a fertilised egg can implant.

Your cervical mucus can give you clues about when you are fertile. At the beginning and end of your cycle, your cervical mucus is creamy, sticky and thick. Around ovulation, it becomes wetter, more transparent, slippery and stretchy like raw egg white. You may be able to stretch your cervical mucus between your thumb and forefinger.

Another way of identifying your fertile time is to keep track of your basal body temperature (your temperature immediately on waking). It may help you know if you have ovulated, as your basal temperature dips slightly before ovulation and rises afterwards. Using your temperature, along with observing the changes in your cervical mucus, can help you to identify when you are fertile to help you conceive.

You may choose to use an ovulation kit or fertility app or monitor to help you track your cycles. Ovulation kits involve testing your urine on specific days in your cycle to detect luteinising hormone (LH) which surges 24–36 hours before ovulation. There are now many different fertility apps and monitors available, some providing you with more accurate information than others. It is worth doing your research to decide on the best one for you.

While all of the actions discussed above can help you to optimise your ability to conceive, it is necessary to remember that having regular sex, every 2-3 days, is the most critical factor in helping you to get pregnant.

How is fertility investigated?

Chapter 5

How is fertility investigated?

Discover the different methods a doctor may use to investigate your fertility and the possible treatments used to achieve parenthood.

As discussed earlier, if you have been trying to conceive for 12 months and are under the age of 35, or 6 months if over 35, then now is the time to see your doctor. Your doctor will arrange some tests for both you and your partner.

Blood tests

These are usually the first tests needed to investigate fertility. Your doctor can arrange the tests for you, or you might like to look at the Medichecks fertility tests here. These tests are to check your hormones to make sure that your levels are normal at certain stages of your cycle, as well as your thyroid function and other markers that are important for good fertility. Men can also check their testosterone levels if they wish.

The Fertility Podcast: Introducing our new fertility tests

Sperm test

After you have the results of your blood tests, your partner should have a sperm test (also known as a semen analysis). Your partner's doctor can arrange a semen analysis to check the quality and quantity of his sperm. The results are usually available within a week. Once you have your results, your doctor will discuss the results with you. These can be confusing at first. However, NICE (2013) recommended that all results of a semen analysis should be compared with the following World Health Organization reference values:

  • Semen volume: 1.5 ml or more
  • pH: 7.2 or more
  • Sperm concentration: 15 million sperm per ml or more
  • Total sperm number: 39 million sperm per ejaculate or more
  • Total motility (percentage of progressive motility and non -progressive motility): 40% or more motile or 32% or more with progressive motility
  • Vitality: 58% or more live sperm
  • Sperm morphology (percentage of normal forms): 4% or more.

If your partner's sperm test is abnormal, then your doctor will initially advise lifestyle changes such as reducing alcohol, not smoking etc. and then repeating the sperm test after 3-4 months. You may also want to consider how supplements may help to improve the quality of your sperm. If the second sample remains abnormal, then it is likely that you will both be referred to a specialist to discuss what this means for your fertility and how fertility treatments may help.

Scan

Your doctor may wish for you to have a scan of your pelvis. This scan looks at your uterus, fallopian tubes and ovaries and can identify any concerns that may need further investigation.

Sexual Health

As one of the causes of both male and female infertility is previous sexually transmitted infections, it's essential to consider your sexual health when trying to conceive. Your risks of having a sexually transmitted infection are higher if you have had multiple partners in the past or have not used barrier methods of contraception such as condoms. Unfortunately, many sexually transmitted infections don't have any symptoms, so you may not know if you have one. When you decide to start a family, it's a good idea for you both to see your doctor or local sexual health clinic and have a sexual health screen. Alternatively, you can buy a wide range of sexual health checks from Medichecks. These tests will check for the common sexually transmitted infections that can cause infertility such as chlamydia and gonorrhoea. If you have an infection, it is possible to treat it with antibiotics to reduce the chances of any damage occurring to your pelvic organs which may make it more difficult to conceive.

Referral to fertility specialists

If the investigations you and your partner have had with your doctor identify any concerns, or if you still have not conceived, then your doctor will arrange for you both to be referred to a fertility specialist. The fertility specialist may suggest further investigations such as a hysteroscopy to look inside the uterus and fallopian tubes. If any cause for your difficulties in conceiving is found or if you have still not conceived naturally, you may be offered fertility treatments. See Chapter 6 for more information on what is involved with fertility treatments.

What treatments can help me conceive?

Chapter 6

What treatments can help me conceive?

Learn about the possible treatments that doctors may use to help you conceive.

You may have been trying to conceive for some time and have made healthy changes to your lifestyle but have not conceived naturally. At this point, your doctor may suggest you try fertility treatments to help.

Some fertility treatments such as IUI, IVF and ICSI are only offered on the NHS if you meet specific criteria, such as what age you are. If you don't meet these criteria, then you may need to pay privately for your fertility treatments. One cycle of IVF treatment can cost over £5,000. The National Institute for Health and Care Excellence (NICE) makes recommendations about who should have access to fertility treatments on the NHS. However, currently, local NHS Trusts also decide who can be offered NHS funding and, in general, their criteria differ, from that recommended by NICE. These differences in approaches have resulted in what is often called the 'IVF Postcode Lottery', meaning that in one NHS Trust couples may be eligible for three rounds of IVF on the NHS and in the neighbouring Trust not be offered any.

There are many different types of fertility treatments, and these are described in detail below:

  • Ovulation Induction
  • Intrauterine Insemination (IUI)
  • In vitro fertilisation (IVF)
  • Intra-cytoplasmic sperm injection (ICSI)
  • Donor conception

Ovulation Induction

Ovulation induction medication is not appropriate for all women; however, if you are not ovulating, then you may need this treatment. Common reasons for not ovulating include stress, weight fluctuations and hormonal conditions such as PCOS. Other causes may include disorders of the pituitary gland, thyroid gland and raised prolactin levels. In some cases, failure of ovulation is due to premature ovarian failure.

If ovulation does not occur, then ovulation induction medicines which you take at the start of your menstrual period can stimulate egg production. If oral medication doesn't work, then more powerful fertility injections may be necessary to stimulate egg production in the ovaries.

Two main drugs called Clomiphene or Clomid (alternatives are Tamoxifen and Letrozole tablets) are used to induce ovulation. These drugs increase the production of follicle-stimulating hormone (FSH) by the pituitary gland, stimulating follicles and egg growth. You usually take this medication in a low starting dose in the first few days of your cycle, and your doctor increases the dose as necessary. If this treatment doesn't work, then daily injections of drugs called Gonadotrophins can be given.

You will be monitored by ultrasound scans to check how you have responded to the medication, and you will be encouraged to have intercourse as soon as the follicles have reached a specific size. Alternatively, you will have an injection of HCG (human chorionic gonadotrophin), a hormone which helps an egg to mature and be released which can help to facilitate the timing of intercourse or other fertility treatments.

As a result of ovulation induction treatments, some women may experience Ovarian Hyperstimulation Syndrome (OHSS), which is when your response to the treatment is exaggerated, and your ovaries become swollen and tender. Symptoms can include pain, bloating, nausea and diarrhoea and often begin within a week of starting treatment. Symptoms can range from mild to severe. In severe cases, OHSS can lead to hospitalisation and even death; however, this is very rare due to the careful monitoring that accompanies ovulation induction treatment. Multiple pregnancies are also a risk of ovulation induction, but again with careful monitoring, this is less likely.

Intrauterine Insemination (IUI)

IUI is a process which involves inserting sperm inside a woman's uterus to facilitate fertilisation. You can use your partner's sperm or, if using a donor, by using frozen donor sperm. The sperm is washed and filtered to obtain a concentrated sample. A thin, flexible tube is inserted through the cervix, and the sperm is placed into the uterus where they are left to fertilise the eggs naturally. You may be offered IUI in a natural cycle, or you may take fertility medication to stimulate ovulation and control the timing of your IUI.

IUI is one of the more straightforward and natural forms of assisted fertility treatments. Its goal is to increase the number of sperm reaching the egg and achieving fertilisation inside the body (unlike IVF, where fertilisation takes place outside the body).

If you're in a same-sex relationship, you may be offered IUI, or you might be offered it before trying IVF. You may also be recommended IUI if you're unable to have sex vaginally, due to a physical or psychosexual problem, or if one of you has HIV.

As with any fertility treatment, the success of IUI depends on several factors. While IUI is a less invasive and less expensive treatment option, pregnancy success rates from IUI tend to be less than IVF. The younger you are and the better the sperm quality, the higher your chances of success. You are also more likely to get pregnant if you take fertility drugs to help stimulate your natural cycle. Fertility clinics can advise on this and what is the best option for you.

In Vitro Fertilisation (IVF)

IVF treatment has been around now for over 40 years and is an assisted technology used to help with infertility. In IVF, the egg is removed from the woman's ovaries and fertilised with sperm in a laboratory. The process involves suppressing, monitoring and stimulating a woman's ovaries, removal of eggs and placing them with the sperm to fertilise the laboratory.

You will usually be offered sedation and pain medication during the egg retrieval process. Transvaginal ultrasound aspiration is the usual retrieval method which uses an ultrasound probe inserted into the vagina to identify follicles. The eggs are then carefully removed from the follicles through a needle connected to a suction device.

Any eggs and sperm that fertilise and become an embryo will be monitored for 2–6 days after which one, or sometimes two, healthy embryos will be transferred into the uterus. Any remaining embryos may be frozen for use in the future. You are usually advised to do a pregnancy test around ten days - 2 weeks after your embryo transfer to see if your IVF cycle has been successful.

IVF can be carried out using your eggs and your partner's sperm, or eggs and sperm from donors. Whether your IVF treatment is successful will depend on things like your age, and the cause of infertility (if it's known). Older women may be doing IVF with donor eggs, which can have a higher success rate.

Intra-cytoplasmic sperm injection (ICSI)

Treatment using ICSI is the same as with IVF; however, instead of mixing the sperm with the eggs and leaving them to fertilise, a single sperm is injected into the egg. This maximises the chance of fertilisation as it bypasses any problems the sperm may have in fertilising the egg.

ICSI may be offered to you as a couple if your partner has abnormal sperm or if you have had previous unsuccessful IVF. Sometimes sperm can only be obtained by surgical removal from the testicles (as a result of an earlier vasectomy, blockage or a co-existing condition) or if your partner has a genetic condition affecting his sperm.

ICSI is very successful in helping sperm to fertilise the egg; however, as IVF itself still has a low success rate, it may not affect the likelihood of your treatment being successful.

Donor Conception

Donor conception is increasingly common, especially for couples who have problems with egg or sperm quality. Donor conception may also be used for same-sex couples who want to start a family, as well as women who might have already had a child but are struggling to conceive a sibling. Donor conception can involve eggs, sperm or embryos.

The methods used in a clinic may vary depending on the situation and need. You might seek treatment abroad or as a private arrangement. It is a very personal decision about whether donor conception is right for you and your family. Laws vary from country to country, as do the rights of any donor child to seek out their biological parent. You will need to consider what this means for you if you decide to go ahead.

The majority of international fertility clinics offer donation and can help guide you through the donor selection process. There are also specialist agencies which can assist in matching you with a donor.

The Donor Conception Network in the UK offers workshops, sessions and support, designed for anyone – from preliminary steps to picking a donor, to raising a donor child.

Top 10 common fertility myths

Chapter 7

Top 10 common fertility myths

Explore the most common myths surrounding fertility.  

There are many myths associated with fertility. In this chapter, we debunk 10 of the most common myths and give you the correct answers you need.

  1. Infertility is a woman's problem.
  2. Infertility affects both men and women equally. Approximately 25% of infertility relates to the male partner, 25% relates to the female, 25% is a combination of both factors and 25 % unknown.

  3. Just relax, and you'll get pregnant.
  4. Being told to relax can be extremely upsetting for couples who are struggling to conceive. While being stressed may impact how quickly you conceive, infertility is a medical condition, and in general, there is a physical reason why you have not yet been able to start a family. However, trying to reduce the stress in your life will help you to cope better emotionally during your fertility treatments.

  5. Fertility drops off a cliff at 35.
  6. Yes and no! There is no denying biology, and that you are more fertile in your teens and twenties. However, it is your fertility reserve (the number and quality of viable eggs in your ovaries) that matters. Some women can go on conceiving in their late 30's and 40's, but as both egg and sperm quality reduce as you get older, it can be more difficult for couples to conceive later in life. It is recommended that you don't wait until your late 30's before trying to conceive, as it is more likely that you will struggle and require fertility treatments, and these are less likely to be successful.

  7. Complementary therapies are effective fertility treatment.
  8. Unfortunately, there is no evidence to suggest that using complementary therapies alone can help you conceive. However, complementary therapies such as acupuncture used in conjunction with fertility treatments may be a useful addition to your treatments, especially if they help you feel more relaxed and positive.

  9. IVF will fix it.
  10. While IVF helps many couples achieve pregnancy and create their family, it still has high failure rates and therefore should not be considered as a 'fix all' solution. The success rates with one IVF cycle are very low, but your chances of success increase with each cycle, with research showing that more couples conceive with their 3rd or subsequent cycles.

  11. If you have one child, guarantees you can have another one.
  12. Having had a successful pregnancy does not guarantee that that you'll become pregnant easily the second time around. Secondary infertility (the inability to conceive after having a pregnancy previously) is very common; it can be very frustrating for couples who are trying to conceive a sibling for their already existing child.

  13. It's fine to smoke when you're trying to conceive, but you need to stop once pregnant.
  14. Smoking is the single most damaging lifestyle factor when it comes to egg and sperm health. You are less likely to conceive if either of you smokes. Couples who are trying to conceive should consider giving up smoking before they start to try to get pregnant.

  15. Miscarriages run in families.
  16. There is no evidence to suggest that because your mother or other female relative had a miscarriage that you will too. Unfortunately, miscarriage is very common, and most of the causes of a miscarriage are unknown. The majority of couples who have experienced a miscarriage will go on to conceive a healthy baby.

  17. Taking contraception can make it difficult to conceive later on.
  18. Using contraception does not affect your ability to conceive later on. However, some methods of contraception like the combined oral contraceptive pill or the injection may delay your fertility for a few months. After this time, your fertility will be back to normal.

  19. It won't make a difference if I lose weight.
  20. Being overweight can make it more difficult for you to conceive, especially if your weight gain is stopping you from ovulating. Being overweight also increases your likelihood of having a miscarriage. Losing just a small percentage of your body weight can make a considerable difference to your fertility. Equally, if your weight is too low, this can mean it is more difficult for you to conceive. Having a healthy BMI increases your likelihood of conceiving and having a healthy pregnancy.

Where can I get support?

Chapter 8

Where can I get support?

Discover the different support networks for fertility problems.

If you have been trying to conceive for some time, you may be finding that it is starting to impact on how you are feeling emotionally. Struggling to conceive or going through fertility treatments can be very hard, and it is quite normal to feel sadness, frustration, anger and despair. It is essential to build a good support network around you of family and friends to support you on the difficult days. Professionals and charitable organisations can help answer any questions you may have. Luckily there are many places you can look to for support and information.

The Fertility Network UK -is a national charity for anyone who is or has experience fertility problems. They offer resources, news and information on their website, a support line to answer your questions directly and details of local support groups close to you.

The HFEA - is the Government regulator for fertility clinics, and the HFEA website also provides impartial information on UK fertility clinics, fertility treatments and egg and sperm donation.

The Daisy Network - is a charity dedicated to supporting women with POI. They provide a network of people to talk to, advice on the treatments available, and keep you updated on research in HRT and assisted conception. If you become a member, you will receive benefits such as access to The Daisy Network Forum and their closed Facebook group, access videos and live chat, factsheets and much more.

The Donor Conception Network - is a supportive network that offers specialist and peer support, local support groups, advice and information for anyone considering using a donor to create their family.

Appendix

Appendix 1:

BMI Calculator

Glossary of Terms

Blocked fallopian tubes:

The most common cause of tubal factor infertility is a previous infection such as from Chlamydia or Gonorrhoea infection that can cause scarring and blockage of the fallopian tubes. This can also occur following surgery to the fallopian tubes or pelvis.

Chlamydia

Common sexual transmitted infection. It's passed on through unprotected sex (sex without a condom) and if left untreated can impact on your ability to conceive.

Donor conception

Donor conception is when eggs, sperm or embryos are used from donors to help aid conception.

Endometriosis

Endometriosis is a painful condition caused by the lining of the uterus growing outside the womb.

Erectile dysfunction

Erectile dysfunction (ED), also known as impotence, is the failure to achieve an erection and therefore can impact on your ability to conceive. It is a very common concern and in particular in men over 40.

Gonorrhoea

Gonorrhoea is a sexually transmitted infection caused by bacteria called Neisseria gonorrhoeae or gonococcus. It is transmitted through unprotected vaginal, oral or anal sex. If left untreated, it can impact on your ability to conceive.

Hypogonadism

Hypogonadism is a hormonal condition due to the lack of the male sex hormone testosterone. Hypogonadism appears to affect around 5 in 1000 men.

Intrauterine Insemination (IUI)

Intrauterine insemination (IUI) is a fertility treatment where sperm is inserted directly into a woman's uterus.

Intra-cytoplasmic sperm injection (ICSI)

Treatment using ICSI is the same as with IVF; however, a single sperm is injected into the egg.

In vitro fertilisation (IVF)

IVF means that an embryo is created outside the body. An egg is removed from the woman's ovaries and fertilised with sperm in a laboratory.

Ovulation Induction

Ovulation induction is the treatment to induce ovulation in a woman who is not ovulating or may not be regularly ovulating.

Polycystic Ovary Syndrome (PCOS)

Polycystic Ovary Syndrome is a common condition affecting how a woman's ovaries work. It causes irregular periods, high levels of male hormones and multiple cysts on the ovaries.

Premature Ovarian Insufficiency:

Premature Ovarian Insufficiency (POI) is premature or early menopause.

Primary Infertility

When someone who has never conceived a child is struggling to conceive

Secondary Infertility

Secondary infertility occurs when a woman is struggling to conceive after already having had a pregnancy or child.

Thyroid conditions

Low thyroid function (hypothyroidism) and an overactive thyroid (hyperthyroidism) are common reasons why some women may find it difficult to conceive and are related to disorders of the thyroid.

Unexplained Infertility

Unexplained infertility is a common infertility diagnosis and means that no known cause for difficulty in conceiving can be found.

Uterine Abnormalities

A uterine abnormality means that there is something wrong with the uterus such as fibroids or anatomical disorders of the uterus.

Varicocele

A varicocele is a cluster of enlarged veins in the testes, similar to varicose veins in the legs.

References

[1] Dunson DB, Baird DD, Colombo B [2004]. Increased infertility with age in men and women. Obstetrics and Gynecology 103: 51–6). http://www.endometriosis-uk.org last accessed 09/01/20

[2] Esteves, S.C., Zini, A., Aziz, N., Alvarez, J.G., Sabanegh, E.S. and Agarwal, A. (2012) Critical appraisal of world health organization's new reference values for human semen characteristics and effect on diagnosis and treatment of Subfertile men, Urology, 79(1), pp. 16–22. doi: 10.1016/j.urology.2011.08.003.

[3] NICE (2013) Quality statement 4: Semen analysis. https://www.nice.org.uk/guidance/qs73/chapter/quality-statement-4-semen-analysis . Last accessed 20.01.20