Infertility is difficulty conceiving a child. On average, one in eight couples consult a doctor for suspected infertility. However, this is not always definitive: a natural pregnancy may still be possible. An update on treatments and possible solutions in the event of difficulty. 

We speak of infertility in the event of difficulty obtaining a pregnancy, which translates into “the absence of pregnancy despite unprotected sexual intercourse for a period of at least 12 months”, notes the National Institute of Health and of medical research (Inserm). It is distinguished from sterility, which is the total inability to procreate naturally (when the chances of obtaining a pregnancy are zero). Note that between a third and half of pregnancies occur after six months of attempts. “This low “reproductive output” compared to other animal species could be explained in part by a high rate of spontaneous miscarriages, very early in the pregnancy, most of which are not even detected.”

After the 12 month period, many couples who are unable to conceive seek medical assistance, which can resolve a certain number of cases of infertility. Treatments are offered to couples, and vary depending on the causes and the profile of the patient(s).

What are the causes of infertility?

In women, infertility can be caused by:

  • Polycystic ovarian syndrome (PCOS);
  • Ovarian insufficiency, which leads to an “alteration of oocyte quality, with an increase in the rate of spontaneous miscarriages and fetal chromosomal anomalies”, according to Inserm
  • Premature ovarian failure, “abnormally significant follicular loss associated with the absence of a menstrual cycle, with early menopause occurring before the age of 40”
  • Bilateral tubal stenosis, that is to say the reduction in the permeability of the fallopian tubes, blocking the passage of sperm to the egg
  • Uterine abnormalities (Rokitanski syndrome (absence of uterus), malformations, endometrial polyps, certain uterine fibroids)
  • Endometriosis.

In men, infertility can be caused by:

  • Testicular failure: sperm abnormalities are the most common causes of infertility in men. The quality and quantity of spermatozoa is altered
  • Sexual dysfunctions:  independently of erectile and ejaculation disorders of psychogenic origin, vascular, hormonal, metabolic or neurological factors can lead to sexual dysfunction”, notes Inserm.

Certain causes common to both sexes: hypothalamic-pituitary pathologies, “responsible for an alteration in the production of hormones which can lead to the absence of ovulation (…) or a deficit in sperm production”, observes the Inserm. Certain cancer treatments such as chemotherapy can also lead to infertility. Finally, other factors such as tobacco, overweight, obesity, stress, or even exposure to certain pesticides, solvents and heavy metals are incriminated.

What are the symptoms of infertility?

What we can call a symptom of infertility is the inability to conceive a child after a year of unprotected sexual intercourse. Other signs may appear or accompany this inability to conceive, such as erectile dysfunctionpain in the testicles for men, and abnormal menstrual cycles for women. 

After 12 months of unsuccessful attempts, it is advisable to carry out an infertility assessment, during which a fertility specialist will try to find out with you why pregnancy is not occurring, in order to maximize your chances for a natural pregnancy, or offer you alternative solutions. He will question you in particular about your history, your lifestyle and will prescribe medical examinations if necessary. If you are trying to have a child and you or your partner suffer from certain pathologies (chronic illnesses, genetic diseases), do not wait the recommended 12 months before consulting a fertility specialist! 

Prevention is better than cure: consider the preconception consultation, which allows you to detect very early if problems could hinder conception.

What treatments for female infertility?

When an infertile couple is taken care of, there are three types of treatments:

  • Medical treatment
  • Surgical treatment
  • Medically assisted procreation (AMP or PMA): intrauterine insemination, in vitro fertilization (IVF) and assisted fertilization by intra-cytoplasmic microinjection (ICSI).

Medical treatment for female infertility: ovarian stimulation

The woman’s ovaries are stimulated to better control her ovulation which is absent (anovulation) or irregular (dysovulation). This ovarian stimulation or ovulation induction is done by the hormone FSH (Follicle Stimulating Hormone), which allows one or two follicles to develop and lead to the maturation of one or two oocytes. It may be enough to treat infertility. 

This stimulation must be monitored by ultrasound and hormonal measurements. It is carried out by subcutaneous injection and can last two to three weeks. Ovulation induction can also be performed as part of in vitro fertilization (IVF) and intracytoplasmic injection (ICSI), to increase the chances of obtaining embryos.

Drug or injection treatment for female infertility

Different treatments can be offered to you depending on the quality of your ovulation:

  • Clomiphene citrate supplemented with estrogen to improve cervical mucus;
  • A treatment by injection of gonadotropin hormones, the hormones that stimulate the gonads, or sexual glands, to carry out their reproductive functions. These gonadotropins are used alone or in combination with clomiphene (one injection every day or every other day for 6 to 12 days, in the first part of the cycle).

Female infertility: artificial insemination

It is preceded by ovarian stimulation. It involves injecting selected sperm into the woman’s uterus at the time of ovulation. The objective: we bypass the cervical mucus in the event of an anomaly and we promote rapprochement between the oocyte and the spermatozoa. The treatment is carried out as a continuation of ovarian stimulation, which allows sperm to be deposited at the optimal time.

Sperm collection is scheduled on the day of insemination after a period of sexual abstinence of 2 to 6 days. It is then prepared in the laboratory in order to reproduce the changes it undergoes during sexual intercourse by passing through the cervical mucus.

Female infertility: in vitro fertilization (IVF)

IVF allows fertilization to take place in a “test tube” and can therefore be better controlled. The embryo (or embryos) formed after two to three days is then either transferred to the uterus for the normal continuation of a pregnancy, or frozen.

Before getting started, you must be aware that this is a very tiring ordeal for the couple. There is first ovarian hyperstimulation with even greater monitoring (ultrasound and blood test) of the growth of the follicles. Then, we proceed to trigger ovulation. The liquid contained in each of the follicles present is punctured with a needle, within twelve hours, and under local or general anesthesia. Each oocyte is then placed in contact with the previously collected sperm. Three days later, if fertilization has occurred, embryo transfer into the uterus can take place. You have to wait fourteen days on average to find out if the transfer was successful and if a pregnancy is progressing.

Female infertility: microinjection or ICSI (intra Cytoplasmic Sperm Injection)

In IVF with ICSI (English: “Intra cytoplasmic sperm injection”), the steps are identical to classic IVF, but the oocyte is placed in direct contact with a single previously selected sperm. It begins like a classic IVF but, instead of culturing the oocytes and spermatozoa and waiting for fertilization, the biologist himself introduces, under a microscope, a mobile spermatozoon into each punctured oocyte.

Infertility and endometriosis

Endometriosis is often diagnosed during an infertility assessment,” notes the French Association for the Fight against Endometriosis. Often associated with infertility, however only 30 to 40% of women affected by endometriosis face an infertility problem.

In the event of endometriosis, and if pregnancy does not occur, medically assisted procreation techniques are recommended: stimulation of ovulation, artificial insemination, in vitro fertilization.

What treatments for male infertility?

As with female infertility, the treatment of male infertility involves:

  • Treatment which includes medication
  • Surgical treatment
  • Medically assisted procreation (AMP): intrauterine insemination, in vitro fertilization (IVF) and assisted fertilization by intracytoplasmic microinjection (ICSI).

But apart from anatomical problems (obstruction of the spermatic passages, etc.), which will be corrected surgically, the responses to male infertility most frequently involve techniques to aid procreation.

Male infertility: drug treatment

They vary depending on the causes of infertility:

  • In the context of testicular dysfunction, hormonal treatment gives good results. In the case of artificial insemination, this treatment can be prescribed with the aim of improving the quality of the sperm; 
  • In case of prostatitis (prostate infection) or STD, antibiotics are prescribed;
  • In certain cases of infertility with an immunological cause, it is possible to prescribe corticosteroids.

Treating male infertility with genital surgery

In men, genital tract surgery is considered to restore the patency of the genital tract. It may in particular be decided in the event of limited narrowing of the vas deferens or when the patient suffers from a significant testicular varicocele (varicose veins appear around the veins surrounding the testicles, altering the formation of spermatozoa). 

Male infertility: aids to procreation

More cumbersome, and sometimes representing a real obstacle course for infertile couples, it is often medically assisted procreation which best circumvents fertility problems. It is thanks to these different techniques that both male and female infertility are best treated. 

Depending on the problem, the doctor, an uro-andrologist specializing in fertility problems, will suggest artificial insemination (introducing previously prepared sperm into the uterus on the day of ovulation) or even IVF, often combined to an ICSI.

“reasonable” spermatogenesis abnormality is not always an obstacle to spontaneous procreation, but statistically, the delays will be longer. The use of PMA  (medically assisted procreation) will therefore depend on the time one is prepared to wait.

You should know that “the success rate of IVF (in vitro fertilization) decreases significantly after the age of 37 in women”, specifies Elise de La Rochebrochard, researcher in epidemiology of human reproduction at INED (National Institute of demographic studies). And the miscarriage rate, during artificial insemination, increases with the age of the father, reaching 35% when the latter is over 40 years old.

Fertility problem: advice for managing the ordeal as a couple

Most couples facing infertility experience a feeling of injustice. Not being able to give the other a child generates guilt, which must be defused within the couple.

Here are some keys to better managing the ordeal for two:

Know how to communicate with others

Reintegrate speech and complicity, work on self-esteem and others despite the ordeal, an approach that is essential. “It’s in your head, you think about it too much”… These thoughts reinforce doubts: “If I can’t do it, then it’s my fault!” Relax. Even if some infertility can result from psychological blockages, these cases mainly concern heavy stories.

Resolve grudges and resentment

In addition to the rejection of someone who is infertile and the fantasies associated with it, “if I had stayed with my ex, I would already have children”, it is necessary to overcome the feeling of unease with regard to the family, friends or colleagues. Knowing that a natural function in others is complex for oneself causes jealousy. This is even more glaring in siblings where it awakens old emotional competitions. In addition, a feeling that is difficult to express is then transferred to strangers: “I can no longer stand seeing children in the street”, “the front page of celebrity newspapers with pregnant stars annoys me…”. These couples feel out of step with, as a result, the risk of gradually isolating themselves.

Break the silence and free the floor

Although the cause of infertility is female in 60% of cases, it is often the woman who takes responsibility for infertility towards others and the family. A lie by omission, because it is difficult to question the spouse’s virility. But who should we entrust this dark secret of infertility to? Breaking the silence and sharing sadness are important steps“It is not painful to speak; what hurts is to experience failure,” assures Léa Karpel, clinical psychologist at the Antoine-Béclère hospital in Clamart. If one of the partners has expressly requested silence from the other, then a conflict of loyalty arises: betraying the promise made to the spouse or lying to his or her family. Together or with the help of a psychologist, the couple must learn to free their speech.

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