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Sexual health
If a woman of reproductive age has sexual intercourse without using contraception she should expect to conceive within two years. If the woman does not become pregnant by this time then she or her partner may be infertile or sub-fertile. Infertile means that she will not be able to conceive, sub-fertile means that she may be able to conceive with some form of medical intervention.

Fertility problems can affect anyone of reproductive age, males and females. It is estimated that 1 in 7 couples in the UK seek medical help in order to conceive.
To become pregnant, an egg from a woman's ovary must pass into the fallopian tube, where it is fertilised by a sperm from a man, before becoming embedded in the lining of the uterus where it develops into a baby. There are many things that can stop this natural process from occurring and which can result in a couple being unable to have children.

Female infertility or sub-fertility
Problems with ovulation occur in about a quarter of all couples who are having difficulty conceiving. There may be something wrong with the ovary itself, or an imbalance of the hormones that control the development and release of an egg. Polycystic ovary syndrome is a condition where tiny cysts (small follicles containing eggs) grow in the ovaries. The cysts do not in themselves cause any fertility problems, but some women with this condition will have irregular, infrequent or absent periods and will fail to ovulate, causing fertility problems.

Premature menopause occurs when a woman undergoes the menopause before the age of forty. The woman will experience an absence of her periods often associated with flushes and sweats. At this time the ovary finishes producing eggs. There is rarely any clear reason for this, although it sometimes runs in families.

Endometriosis is a common condition where the cells which normally line the uterus grow elsewhere (usually within the pelvis). When it is severe, endometriosis can affect fertility by causing adhesions which may damage the ovaries and fallopian tubes.

Blocked or damaged fallopian tubes prevent conception occurring as the egg cannot travel down them to meet the sperm. Pelvic inflammatory disease is often responsible, and this can occur without any symptoms. The causes of pelvic inflammatory disease are numerous and may include childhood appendicitis and sexually transmitted infections, particularly Chlamydia, the incidence of which is rising dramatically.

Infertility in women is also linked to age. Women in their early twenties are about twice as likely to get pregnant as women in their late thirties. The biggest decrease in fertility appears to happen around the mid-thirties. This is causing a lot of problems for women who decide to delay starting a family because of their career.

Male infertility or sub-fertility
Male infertility is either the major factor or a part of the problem in at least half of all couples who experience difficulties conceiving. The semen may contain too few sperm or even no sperm at all. The sperm itself may be shaped abnormally indicating damage, or they may not be very motile (unable to swim from the vagina up into the fallopian tube to fertilise the egg). The causes of these problems with sperm production and quality may be due to physical problems such as chemicals, alcohol, overheating of the testicles, injury, or infections such as mumps. Other factors which influence the quantity and quality of sperm in the ejaculate include insufficient levels of the necessary hormones, certain genetic problems or obstructions in the man's reproductive tract in the testicles. In the majority of cases however no cause is found.

Around 10% of couples who present with fertility problems will be termed as having unexplained infertility. In many cases of unexplained infertility the problem may be a very prolonged delay in achieving a pregnancy rather than any factor preventing pregnancy.
In most cases, there are no symptoms of fertility problems. Couples just think that it is taking a long time to conceive and may not realise that something is wrong. If infertility arises as a result of polycystic ovary syndrome, early menopause or endometriosis then there may be symptoms. In polycystic ovary syndrome there may be infrequent or absent menstruation, weight problems, acne or an increase in facial and body hair. In early menopause, periods become very irregular and the woman may experience hot flushes, fatigue, heart palpitations, night sweats, irritability and pain in the joints. If the cause is endometriosis, pain is the most common symptom which is usually experienced during periods but can occur throughout the monthly cycle including during ovulation, bowel movements and intercourse.
If treatment is required to help the woman become pregnant, the type of treatment is called assisted conception and will depend upon the diagnosis and whether it is the man, woman or both with the fertility problem. Assisted conception techniques include:

Ovulation induction (OI) - is the name of a treatment where the ovaries are stimulated by drug therapy to ovulate. Intercourse is timed to coincide with ovulation.

Intra-uterine insemination (IUI) - like OI, drug therapy is used to stimulate the ovaries. A semen sample is then prepared by separating the sperm from the liquid surrounding them and placing them directly into the uterus using a thin plastic tube.

In vitro fertilisation (IVF) - IVF has become a common form of treatment for a number of fertility problems. During an IVF cycle, drugs are used to try to stimulate the growth of a number of eggs from the ovary. Ultrasound scans are used to monitor the growth of follicles, which are fluid filled areas in the ovary in which the eggs develop. These eggs are collected by inserting a needle through the vaginal wall into the follicles. The eggs are mixed with sperm from the male partner, and kept in dishes in an incubator until fertilisation occurs. Two or three days later, one or two embryos are loaded into a fine tube which is passed through the cervix and into the uterus.

Intra cytoplasmic sperm injection (ICSI) - may be recommended when there is male factor infertility, or if eggs have either failed to fertilise or fertilise poorly in a previous cycle of IVF. The procedure is similar to conventional IVF, but a single sperm is injected directly into the centre of each egg. The embryo can then be replaced as in IVF.

Gamete Intra Fallopian Transfer (GIFT) - is a procedure in which the eggs are removed from a woman's ovaries and placed in one of the fallopian tubes together with the man's sperm. This allows fertilisation to take place inside the woman's body.

Donor insemination - Insemination using sperm from a donor is carried out during a cycle at the time of ovulation. Sometimes this is performed in a normal cycle, in other cases it can be combined with ovulation induction, IUI or IVF.

Egg donation - is an option for women who have poor quality eggs, or no eggs. The treatment will usually involve a course of drugs to thicken the lining of the uterus prior to the eggs, which have been donated and fertilised with the partner's sperm, being transferred to the uterus as in IVF.
When to see your doctor
The National Institute for Health and Clinical Excellence (NICE) fertility guideline states that people who have not conceived after one year of regular unprotected sexual intercourse, should be offered further clinical investigation, but that where the woman is over 35 years of age or where there is a history of predisposing factors, earlier investigation should be offered.

When you visit your doctor to discuss infertility you should go together as a couple. Your doctor will arrange for blood tests to establish that ovulation is occurring. The male partner will be asked to submit a semen sample for analysis. You will also be tested for the presence of Chlamydia. Depending upon these results, the next step will be for you and your partner to be referred to an infertility specialist who will treat or further investigate as appropriate. Your doctor will also be able to discuss with you whether you will be able to have assisted conception techniques performed under the NHS or whether you would have to pay for them privately.
Living with sub-fertility or infertility
If you are experiencing difficulty in getting pregnant it may be because you or your partner is not in a sufficiently good state of health which is making you sub-fertile. In such cases, some simple lifestyle changes may increase your chances of conceiving. Smoking affects fertility as does heavy drinking, so if you and your partner smoke or drink, stop smoking and cut down on the amount of alcohol that you drink. Similarly, couples who are overweight may have difficulty in conceiving, while women who are severely underweight may have irregular or absent periods and fail to ovulate. A healthy diet and regular exercise can keep you and your partner in a healthy state. Men should wear loose fitting underwear, avoid hot baths and try not to sit for long periods as heat in the genital area can reduce sperm production.

If, as a couple, you have been told that one of you is infertile, it can be one of the biggest emotional, physical and financial challenges you may face. There will be many questions you will need to ask and many decisions you will need to make. Do not try to brave things out alone. Try to face things together as a couple. If you have family or close friends, share your feelings with them and let them help. Make use of the counsellors, doctors and nurses who are there to provide support and advice about the options available. Consider joining one of the many support groups to learn about other couple's experiences. Use the internet to learn as much as you feel that you need to know to make informed choices.
Further information
Further information may be obtained from Infertility Network UK, the national charity that provides information and support to anyone affected by fertility problems.

Infertility Network UK
Charter House
43 St Leonards Road
Bexhill on Sea
East Sussex
TN40 1JA
Freephone: 0800 008 7464

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