If you don't conceive when you plan to have a baby it can be very frustrating and an emotional rollercoaster ride. Infertility is more common than most people think. Up to 15% of couples who try for a baby will experience fertility problems. Involuntary childlessness can be devastating. When month after month goes by without the much wanted pregnancy happening it is easy to become frustrated and it is well known that infertility can cause emotional distress and may lead to relationship problems.
Having troubles conceiving can be caused by problems with ovulation, blocked fallopian tubes, endometriosis, PCOS, premature menopause, fibroids, thyroid problems and sperm problems. Depending on the cause there are a number of treatment options that can be considered and investigation by your doctor should determine what is appropriate in your own case.
Illness & conditions
Endometriosis is a common and often painful condition that affects approximately ten per cent of women. It occurs when the tissue that normally lines the uterus (the endometrium) grows outside the lining of the uterus. The misplaced tissue commonly grows on the uterine (fallopian) tubes, the ovaries or the tissue lining the pelvis (the peritoneum).
How does endometriosis affect fertility?
It is thought that around 30% of women with endometriosis are infertile, however further research is needed to confirm this.
In mild endometriosis there is no obvious reason why infertility occurs. It may be because the endometriosis cells release chemicals that interfere with the ability to conceive or affect early normal development of the embryo.
In moderate to severe endometriosis, scarring may cause interference with ovulation and the passage of the egg along the tube because of damage or blockage. It can also prevent the sperm from reaching the egg.
Not all women with endometriosis are infertile. Many women have children without difficulty, have already had children before they are diagnosed, or eventually have a successful pregnancy.
Surgical treatment of endometriosis, such as an operation called a laparoscopy to remove the endometriosis, is believed to increase the chances of pregnancy.
In an operation using laparoscopy the overall pregnancy rate was approximately 42% of women with endometriosis . Approximately 45% of women will develop a recurrence of endometriosis after laparoscopic surgery for endometriosis .
If surgical treatment is unsuccessful, in vitro fertilisation (IVF) treatments may also be considered. However, before trying this form of treatment it is important that your endometriosis is properly treated, as the oestrogen levels involved may flare up any existing endometriosis.
Adenomyosis is a condition of the uterus (womb) where the cells which normally form a lining on the inside of the uterus also grow in the muscle wall of the uterus. If adenomyosis is centred in one area, it can lead to a mass of adenomyosis called an adenomyoma.
Adenomyosis is only seen in women in their reproductive years because its growth requires oestrogen. After menopause, adenomyosis lessens because of the lack of oestrogen.
Does adenomyosis affect fertility?
Studies suggest there may be changes in the ability of the uterine muscles to contract appropriately. Also, these endometrial cells inside the muscle may release body chemicals which lead to subfertility.
Fibroids (also known as uterine fibromyomas, leiomyomas or myomas) are non-cancerous growths or lumps of muscle tissue that form within the walls of the uterus (womb).
Fibroids can vary in size ranging from the size of a pea to the size of a rock melon or larger.
It is not known exactly why fibroids occur. However, we do know that the female hormones, oestrogen (estrogen) and progesterone play a significant role in stimulating the growth of fibroids.
Fibroids occur in women of reproductive age, growing at varying rates until the onset of menopause, when they tend to decrease in size and may slowly shrink in size due to the loss of oestrogen and progesterone.
Do fibroids affect fertility?
Infertility is not a common problem for women with fibroids, less than 3% of women may have fertility problems as a result of fibroids. Fibroids can interfere with implantation of the embryo into the uterus, increase the risk of miscarriage or impact the progress of labour depending on the size and position.
Polycystic Ovary Syndrome (PCOS)
PCOS is the most common endocrine (hormonal) disorder in women. Symptoms include menstrual problems such as irregular periods and anovulation (lack of ovulation), high androgen (testosterone) levels which can cause male patterned hair growth and acne and metabolic problems which cause weight gain and an increased risk of type 2 diabetes.
PCOS and fertility
One of the first things you may have been told when diagnosed with PCOS was that the condition can affect your ability to have children. Whilst this is true for some women who have PCOS, 60% of women with PCOS become pregnant naturally. Some women may experience reduced fertility or it may take longer to conceive.
In women with PCOS the hormone changes that can cause irregular cycles may also affect ovulation and therefore affect fertility. Lack of ovulation is the most common cause of infertility in PCOS. An anovulatory cycle is a menstrual cycle in which ovulation fails to occur. This means that you do bleed but do not release an egg or ovulate.
In addition, body weight has an impact on fertility for women especially for those with PCOS.
There are many things you can do to improve your fertility and treatments are available if you have difficulty conceiving. See your doctor to first discuss treatment of your PCOS symptoms tailored to your individual needs. This might include some changes to lifestyle and/or medication.
Premature & early menopause
Premature menopause is when the final period occurs before a woman is 40. The reason for premature menopause may be because:
- your periods stopped spontaneously but early (premature ovarian failure)
- you have had surgery to remove both ovaries (oophorectomy)
- chemotherapy has caused ovaries to fail
Early menopause is when the final period occurs before a woman is 45. Again the reasons may be spontaneous, surgical or chemical.
Effect on fertility
With premature and early menopause, the ovaries run out of eggs earlier than expected and they are unable to produce an egg or the hormones required for pregnancy.
Very rarely, (about a 2-5% lifetime chance), a woman may have a spontaneous pregnancy after a diagnosis of premature/early menopause.
Sometimes, premature/early menopause is diagnosed when a woman has sought help for fertility. If the ovaries fail to respond to the hormones used to produce eggs or if eggs fail to fertilise, these may be signs of premature/early menopause developing.
For a woman who has gone through premature/early menopause, depending on her circumstance her options for having children include:
- a donor egg
- surrogacy with a donor egg
To explore the best option for you, ask your doctor for a referral to a fertility specialist who is a member of one of the in vitro fertilisation (IVF) clinics.
Fertility & chemotherapy
If you have been diagnosed with cancer and premature/early menopause is likely to occur because of treatment for cancer, there are some things you can do before you have the treatment.
Before chemotherapy and/or radiotherapy, you could investigate your options for trying to preserve eggs for conception. There are a number of options including:
- egg preservation
- ovarian preservation
- ovarian biopsy and freezing
This takes place before chemotherapy.
The ovaries are hormonally stimulated to produce eggs and the eggs are then collected.
If you have a male partner, the eggs can be fertilised with your partner's sperm and the embryos are then frozen. When you are ready for pregnancy, the embryos are transferred into the uterus.
If you do not have a partner, the unfertilised eggs may be frozen. When you are ready for pregnancy, the eggs are thawed and a male partner's sperm or donor sperm is used to fertilise them. (This technology is still in development and sadly the success is limited).
Some women are given therapy with a GnRH agonist – a hormone that causes a chemical reaction to control the ovary and eggs temporarily. This therapy is given during chemotherapy. After the chemotherapy stops, the GnRH agonist stops and the menstrual cycle should return. This therapy is not well developed or researched.
Ovarian biopsy & freezing
This procedure takes place before chemotherapy starts. A piece of ovary is excised (cut away) and frozen. After the chemotherapy is complete, the ovarian tissue is transplanted under skin and with hormone stimulation, eggs are collected. This technique has recently shown some success although is still in the research phase.
Your thyroid is a small bowtie or butterfly-shaped gland, located in your neck, wrapped around the windpipe. The thyroid gland takes iodine (mostly found in foods such as seafood and salt) to produce thyroid hormones. Two key thyroid hormones are triiodothyronine (T3) and thyroxine (T4). These hormones help oxygen get into cells and regulate the body's metabolism. The thyroid hormones also affect other important functions of the body such as growth.
There are number of factors that can put you at a higher risk of thyroid disease:
- A personal history of autoimmune conditions, including Type 1 diabetes
- If you have grown up in an area that was iodine deficient
- If you have been exposed to head and neck radiation in the past
Thyroid conditions affect women five times more often than men.
If the thyroid is underactive, symptoms of hypothyroidism may occur. An overactive thyroid gland produces excess thyroid hormones and is called hyperthyroidism.
How a problem thyroid affects fertility and pregnancy
According to Dr Jennifer Wong, a consultant endocrinologist at Monash Health, a number of health problems are associated with a problematic thyroid:
- Decreased fertility making it much harder to become pregnant
- Increased risk of miscarriage
- Increased risk of pre-term or early delivery
- Hypertension (high blood pressure)
- Premature birth
Diagnosing thyroid dysfunction
It is very important to detect thyroid problems in women pre-pregnancy and during the first 12 weeks of pregnancy as the foetus is dependent on the mother's thyroid hormone in the first trimester.
A simple, specific blood test will determine whether you have thyroid dysfunction. You can see your doctor for this test.
If you are diagnosed with a thyroid condition, treatment is quite easy and manageable.
The most common genetic cause of infertility in women is Turner's syndrome.
Turner's syndrome is a chromosomal condition that alters development in females. This condition occurs in about 1 in 2,500 female births worldwide.
It is caused by the complete or partial lack of one of the X chromosomes (female sex chromosome). This results in a range of complications, including stunted growth and development, deafness, an increased risk of heart and kidney problems and infertility. Women with this condition tend to be shorter than average and are usually unable to conceive a child because of an absence of ovarian function.
The majority of women with Turner's syndrome are infertile. There are two types of Turner's syndrome – XO who never have periods and XX/XO Mosaic who can have periods but have an early menopause. Spontaneous pregnancies (less than 5% of women) are associated with a high risk of miscarriage, and chromosomal and congenital abnormalities.
Pregnancy can be achieved at present through IVF technology with donor egg or embryo.
Due to early menopause, women with Turner Mosaic syndrome should not delay exploring their pregnancy options for too long, if this is possible.
Counselling regarding fertility and pregnancy is highly recommended for all women with Turner's syndrome.
Other causes of infertility
Sometimes infertility can't be explained and there is no clear reason why you are not able to conceive a child. For more information on other causes of infertility, visit yourfertility.org.au/not-getting-pregnant
Lee HJ, Lee JE et al. Natural conception rate following laparoscopic surgery in infertile women with endometriosis. Clin Exp Reprod Med. 2013 Mar 40(1):29-32.
Hayasaka S, Ugajin T et al. Risk factors for recurrence and re-recurrence of ovarian endometriomas after laparoscopic excision. J Obstet Gynaecol Res. 2011 Jun 37(6):581-5.
This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at March 2014.