Infertility: Symptoms, Causes & Treatment

Infertility is defined as the inability to achieve pregnancy after 12 months of regular, unprotected sexual intercourse, or 6 months for women older than 35 years. It differs from secondary infertility (loss of fertility after previous pregnancy). Affecting approximately 10-15% of couples worldwide, infertility is a common medical condition requiring proper evaluation and treatment.

Infertility is categorized into two main types: male infertility (related to sperm quality and motility) and female infertility (related to ovulation, fallopian tubes, or uterus). Approximately 40% of cases are due to male factors, 40% to female factors, and 20% to combined or unexplained causes. Treatment depends on accurate diagnosis of the underlying cause.

In Jordan and the Middle East, infertility treatment and microinjection services have advanced significantly, with specialized clinics offering state-of-the-art assisted reproductive technologies (ART). Awareness of the condition and demand for treatment are increasing, providing couples with multiple effective therapeutic options.

Infertility itself has no obvious symptoms; it is defined by failure to conceive despite trying. However, underlying conditions causing infertility may manifest with symptoms. Presentation differs between men and women depending on the root cause.

• In women: Irregular or absent menstrual cycles, heavy or painful menstrual bleeding, pain during intercourse (dyspareunia).
• In women: Pelvic or lower abdominal pain, especially during menstruation, may indicate endometriosis.
• In men: Difficulty with erection or ejaculation, or decreased libido.
• In men: Pain or swelling in the testes or scrotum.
• In both sexes: Unexplained weight gain or difficulty losing weight.
• In both sexes: Acne or excessive hair growth (signs of hormonal imbalance).
• In both sexes: Persistent fatigue and tiredness.
• In women: Spontaneous breast discharge (galactorrhea) may indicate elevated prolactin.

• Ovulatory disorders in women: Irregular or absent ovulation due to polycystic ovary syndrome (PCOS), hormonal imbalances, or elevated prolactin levels.
• Sperm abnormalities in men: Low sperm count, poor motility, or abnormal morphology (oligospermia, asthenospermia, teratospermia).
• Fallopian tube damage or blockage: May result from pelvic infections, previous surgery, or endometriosis.
• Uterine and ovarian disorders: Uterine fibroids, ovarian removal, or poor endometrial development.
• Immunological factors: Antibodies against sperm or immune system imbalances.
• Ejaculation problems in men: Inability to ejaculate (azoospermia) or retrograde ejaculation.
• Psychological stress: Chronic stress and anxiety may impair fertility in both partners.
• Unexplained infertility: In 10-20% of cases, no specific cause is identified despite comprehensive testing.

• Age: Fertility declines after age 35 in women and 50 in men due to reduced egg and sperm quality.
• Obesity and overweight: Affect hormonal balance and reduce conception chances.
• Smoking: Impairs sperm quality in men and ovarian reserve in women.
• Alcohol and drug use: Negatively affect fertility and reproductive capacity.
• Chronic diseases: Diabetes, thyroid disorders, cardiovascular diseases.
• Previous infections and STIs: May cause scarring and tubal damage.
• Environmental toxins and radiation exposure: May harm sperm and egg quality.
• Chronic psychological stress: Affects reproductive hormones.
• Certain medications: Antidepressants, antihypertensives, and others may impact fertility.
• Unsafe sexual practices: Increase risk of infections and inflammation.

Accurate diagnosis of infertility requires comprehensive evaluation of both partners. It begins with detailed medical history and physical examination, followed by specialized tests and imaging. The duration and investigations vary based on age and other factors.

• Medical history and physical examination: The physician inquires about duration of attempts, menstrual history, previous diseases, medications, and performs general and local physical examination.
• Semen analysis: The primary test for men, measuring sperm count (normal > 15 million/mL), motility (> 40%), and morphology.
• Hormone testing in women: FSH, LH, estradiol, progesterone on specific cycle days (days 3-5 and 21), plus prolactin and thyroid hormones (TSH, T4).
• Hormone testing in men: Testosterone levels and gonadotropins (FSH, LH) to assess testicular function.
• Ultrasound examination: For women: to assess ovaries, follicle count, and endometrial thickness. For men: to examine testes and seminal vesicles.
• Hysterosalpingography (HSG): X-ray with dye to visualize uterine shape and check for fallopian tube blockage.
• 3D transvaginal ultrasound: Comprehensive assessment of uterine cavity and ovaries.
• Hysteroscopy: Used if uterine abnormalities or fibroids are suspected.
• Laparoscopy: Employed in complex cases to investigate endometriosis or pelvic adhesions.
• Ovulation tracking: Determining ovulation day by basal body temperature or urine LH surge testing.

Medications

• Clomiphene citrate: Oral medication to stimulate ovulation in women, especially for PCOS. Usual dose 50-150 mg daily on days 3-5 of the menstrual cycle.
• Gonadotropins (FSH, LH): Injections to stimulate multiple follicle development, used with ICSI or IVF.
• Metformin: For women with PCOS, improves insulin sensitivity and regulates menstrual cycles.
• Thyroid hormone replacement: Levothyroxine if hypothyroidism is present.
• GnRH agonists/antagonists: Used with IVF to prevent premature ovulation.
• Progesterone: Given in the luteal phase to improve endometrial thickness and implantation chances.
• Aromatase inhibitors (Letrozole): Newer alternative to clomiphene, may be superior in some cases.
• Low-dose aspirin: May improve blood flow to the endometrium, though evidence is limited.

Procedures and Surgery

• Intracytoplasmic Sperm Injection (ICSI): A single sperm is injected directly into an egg, highly effective for severe male factor infertility.
• In Vitro Fertilization (IVF): Eggs are retrieved, fertilized in the laboratory, and embryos transferred to the uterus. Success rates: 30-50% depending on age and cause.
• Ovarian rejuvenation (PRP injection): Emerging technique offering hope for women with low ovarian reserve.
• Endometriosis surgery: Removal of endometrial tissue to improve natural conception chances.
• Myomectomy: Removal of uterine fibroids that impede pregnancy.
• Tubal catheterization: For simple proximal tubal blockage.
• Varicocelectomy: Repair of testicular varices, may improve sperm quality.
• Surgical sperm extraction (TESE, PESA, MESA): Direct extraction from testicles in azoospermia cases.
• Intrauterine Insemination (IUI): Processed sperm injected into the uterus on ovulation day, less expensive but less effective than IVF.

Lifestyle Changes and Practical Tips

• Weight loss and maintaining healthy weight: Loss of 5-10% body weight can improve fertility, especially in PCOS.
• Stop smoking and alcohol: Smoking reduces sperm and egg quality; alcohol affects hormones.
• Regular exercise: 150 minutes of moderate activity weekly improves fertility.
• Reduce stress and anxiety: Relaxation, mindfulness, and counseling can help.
• Improve sleep quality: 7-9 hours of adequate sleep is essential for hormonal balance.
• Optimize nutrition: Include zinc, folic acid, vitamins, fruits, vegetables, and proteins.
• Avoid toxic substances: Reduce environmental pollutants and use sperm-safe lubricants.
• Maintain regular sexual intercourse: 2-3 times weekly around ovulation increases natural conception chances.
• Avoid excessive exercise: Over-training may harm fertility in elite female athletes.
• Seek psychological support: Treatment takes time; emotional support is crucial.

• Ovarian Hyperstimulation Syndrome (OHSS): Rare but serious complication from stimulation hormones, causing severe abdominal pain, nausea, and potentially blood clots or kidney failure in severe cases.
• Bleeding and infection during egg retrieval: Extremely rare (<1%), but may cause bowel or vascular injuries.
• Ectopic pregnancy: Slightly increased risk with IVF, especially if fallopian tubes are damaged.
• Miscarriage and multiple pregnancies: IVF slightly increases multiples risk, with associated maternal and fetal complications.
• Depression and psychological distress: Repeated treatment failures may cause significant depression and anxiety in couples.
• Financial and social burden: Treatment costs (especially IVF) are very high, creating significant financial and social stress.
• Long-term complications: Some studies suggest a slight theoretical increase in cancer risk with hormone stimulation, though data are inconclusive.

• Maintain healthy weight: Avoid both obesity and extreme thinness.
• Avoid smoking, alcohol, and drugs: Smoking especially impairs sperm and egg quality.
• Practice healthy lifestyle: Regular exercise, adequate sleep, balanced nutrition rich in antioxidants.
• Prevent sexually transmitted infections: Safe sex practices prevent infections that may scar fallopian tubes.
• Manage stress: Relaxation and enjoyable activities improve hormonal balance.
• Regular medical check-ups: Periodic screening for endocrine and reproductive health.
• Minimize environmental toxins: Reduce exposure to pesticides and pollutants.
• Treat chronic diseases promptly: Diabetes and thyroid disease require early management.
• Don't unnecessarily delay conception: Fertility declines with age, especially after 35 in women.
• Preconception counseling: Comprehensive medical consultation before attempting pregnancy can identify issues early.