Fertility Awareness

Q&A with Dr. Rosemary Leonard

Dr. Rosemary Leonard is a well-respected GP with a specialist interest in women’s health. Here she answers a few questions about infertility, some common causes and the treatment options available.

Question: How has the demographic of women having babies changed?

Answer: The demographic of pregnant women coming into my surgery has changed dramatically over the last 30 years. When I started out in Obstetrics & Gynaecology, women having babies were generally in their early to mid-20s. Now it is much more unusual to see women of this age pregnant or trying for a baby. Most women who come through my doors are in their early to mid-30s, a whole decade later. Women today are delaying having children for many reasons – establishing their career, waiting to be able to afford the right house, finding the right partner – and this is having a big impact on fertility levels. Fertility gradually declines in the 30s, particularly after age 35. Each month that she tries, a healthy, fertile 30-year-old woman has a 20% chance of getting pregnant. That means that for every 100 fertile 30-year-old women trying to get pregnant in 1 cycle, 20 will be successful and the other 80 will have to try again. By age 40, a woman’s chance is less than 5% per cycle, so fewer than 5 out of every 100 women are expected to be successful each month.[1]

Question: Have there been any changes in the male demographic?

Answer: For similar reasons, men are also having children later, although this doesn’t have such a big impact as for women. The big story in men is the dramatic decrease in sperm quality. Up to a fifth of young men today have a low sperm count (defined as fewer than 20 million sperm per millilitre of semen[2])  and the number of sperm in each millilitre of semen has halved between World War Two and 1992, while abnormal sperm is on the rise.[3] We can’t be sure why this is happening, although a recent study suggests that a combination of different chemicals found in everyday packaging and toiletries, may be having an impact.

Question: What causes infertility?

Answer: Infertility can be due to problems in the man (in 40% of cases), the woman (in 40% of cases), a combination of both partners or in some cases, no identified reason (in 20% of cases)[4].

Common conditions affecting a woman’s fertility include:

  •  Ovulation problems, which may be linked to diabetes or thyroid disease
  •  Polycystic Ovary Syndrome (PCOS)
  •  Fallopian tube, neck of the womb (cervix) or womb (uterine) problems
  •  Endometriosis
  •  Age – female fertility declines considerably after 35
  •  Stress, being overweight, underweight and smoking

For men, infertility may be due to:

  • Erection and/or ejaculation problems
  • Inflamed testes
  • Previous bacterial or viral infection affecting  either the testes or the epididymis ( eg mumps )
  • Side-effects of some medicines, such as chemotherapy – enlarged veins within the testes
  • Contact with chemicals or radiation work
  • Genetic problems
  • Being overweight and smoking

Question: What tests are available?

Answer: Infertility tests for women include:

  • Progesterone blood test to check for ovulation
  • Hormone blood tests for irregular periods to check for levels of follicle‐stimulating hormone (FSH) and luteinising hormone ( LH )
  • Chlamydia swab test
  • Thyroid function test
  • Hysterosalpingogram X‐ray to check for blockage of the fallopian tubes
  • Hysterosalpingo‐contrast‐ultrasonography scan to check whether the fluid passes through the tubes
  • Laparoscopy using a special camera passed through a small incision to look closely at the womb, fallopian tubes and ovaries

Infertility tests for men include:

  • A physical examination to check the testicles and penis for any lumps, structural problems or deformities
  • Semen analysis for sperm count, sperm mobility or abnormalities
  • Chlamydia test for this common STI linked to infertility

Question: What are the treatment options available?

Answer:

  •  Medicine to help f stimulate ovulation e.g. clomifene, gonadotropins and metformin
  • Operations and surgical procedures
  • Assisted conception procedures:
    • Home cervical cap insemination kits
    • Intrauterine insemination (IUI)
    • In‐vitro fertilisation (IVF)
    • Egg and sperm donation

Question: How can cervical cap insemination help?

Answer: Cervical caps are an effective technique to aid in conception, previously available through a doctor in clinic or surgery, with success rates of between 15% and 20% recorded. [5], [6], [7], [8]

Cervical cap insemination is quite logical; similar to intrauterine insemination (IUI), the cervical cap allows semen to be placed closer to the cervix for a longer duration, which can help couples with low sperm count and motility. The cap can also assist with issues surrounding an unfavourable vaginal environment, by placing sperm at the opening to the cervix.

The cervical cap prevents the backflow of semen from the vagina as well,1 again maximising time sperm are closer to the cervix, whilst allowing the woman to carry on with her daily activities.

It’s worth noting that IUI ‘washes’ semen away, leaving the sperm which is injected directly into the uterus but the importance of semen in the conception process is becoming more apparent. NICE guidance no longer recommends IUI as a treatment for couples who are having trouble conceiving[9]. NICE says this is because new evidence shows that it is no better at achieving a live birth than people attempting to conceive through regular vaginal intercourse. However, intrauterine insemination may still be suitable in certain circumstances where vaginal intercourse would not be suitable or appropriate, for example:

  • people who are unable to, or would find it very difficult to, have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem, who are using partner or donor sperm
  • people with conditions requiring specific consideration in relation to methods of conception (for example, where the man is HIV positive)
  • people in same-sex relationships

References

[1]American Society of Reproductive Medicine. Age and fertility: A guide for patients. 2012

[2]NHS Choices: Low sperm count http://www.nhs.uk/conditions/low-sperm-count/Pages/Introduction.aspx
[Last accessed May 2014]

[3]Elizabeth Carlsen and others, “Evidence for decreasing quality of semen during the past 50 years,” British Medical Journal, 305, 1992, 609-613

[4]American Society of Reproductive Medicine http://www.asrm.org [Last accessed May 2014]

[5]Flierman PA, Hogerzeil HV, Hemrika DJ. A prospective, randomized, cross-over comparison of two methods of artificial insemination by donor on the incidence of conception: intracervical insemination by straw versus cervical cap. A prospective, randomized, cross-over comparison of two methods of artificial insemination by donor on the incidence of conception: intracervical insemination by straw versus cervical cap. Hum Reprod, 1997, Sep; 12 (9): 1945-8

[6]Corson, Batzer, Otis, Fee. The cervical cap for home artificial insemination. J. Reprod. Med, 1986, May; 31 (5):349-52

[7]Bergquist C A, Rock J A, Miller J, Guzick D S, Wentz A C, Jones G S. Artificial insemination with fresh semen using the cervical cap technique: a review of 278 cases. Obstetrics and Gynecology, 1982; 60(2): 195-9

[8]Subak et al. Therapeutic donor insemination: a prospective randomized trial of fresh versus frozen sperm. American Journal Obstetrics and Gynecology, 1992, June; 166 (6pt 1):1597-604

[9]NHS Choices, New NICE guidelines for NHS fertility treatment, 20th February 2013 http://www.nhs.uk/news/2013/02February/Pages/New-NICE-guidelines-for-NHS-fertility-treatment.aspx [Last accessed May 2014]