Infertility
Failure to conceive after 12 months of regular unprotected intercourse (6 months if over 35) — many causes are treatable.
Overview
Infertility affects ~1 in 7 couples. Causes are roughly one-third female, one-third male, one-third combined or unexplained. Modern assessment and assisted reproduction (IUI, IVF/ICSI) achieve pregnancy in most couples. NHS funding varies by region.
Symptoms
- • Failure to conceive after 12 months (or 6 months if age ≥36)
- • Female: irregular or absent periods, pelvic pain, dyspareunia, galactorrhoea, hirsutism
- • Male: erectile or ejaculatory dysfunction, low libido, small/asymmetric testes
- • Recurrent miscarriage
Risk factors
- • Age — female fertility declines sharply after 35
- • Smoking, excess alcohol, BMI <19 or >30
- • PID, endometriosis, chlamydia history
- • Previous chemotherapy/radiotherapy
- • Anabolic steroid use, testicular trauma/surgery
Causes
- • Female: ovulatory disorders (PCOS, hypothalamic, premature ovarian insufficiency), tubal disease (PID, endometriosis), uterine factors, age
- • Male: oligo/asthenospermia, azoospermia (obstructive/non-obstructive), varicocele, genetic (Klinefelter, CFTR), Y-chromosome microdeletion
- • Combined: anti-sperm antibodies, infrequent intercourse, lifestyle
- • Unexplained (~25%)
🚨 Red flags — seek urgent care
- • Galactorrhoea + amenorrhoea — exclude prolactinoma
- • Hot flushes + amenorrhoea under 40 — premature ovarian insufficiency
- • Suspected ectopic pregnancy on testing — emergency
- • Severe ovarian hyperstimulation during treatment
When to seek care
- • 12 months trying without success (6 months if female partner ≥36)
- • Known risk factor (PCOS, endometriosis, previous chemo, varicocele) — investigate earlier
- • Recurrent miscarriage (≥3) — specialist referral
Diagnosis
- • Female: day 21 progesterone (ovulation), TFTs, prolactin, AMH; transvaginal ultrasound; HSG or HyCoSy for tubal patency
- • Male: semen analysis on 2 samples 4–6 weeks apart; hormonal profile if abnormal; karyotype/CFTR/Y deletion in azoospermia
- • Couple: BMI, rubella immunity, STI screen
- • Laparoscopy if endometriosis or tubal disease suspected
Treatment
- • Lifestyle: BMI 19–30, stop smoking and recreational drugs, moderate alcohol, folic acid 400 µg
- • Anovulation: letrozole (first-line for PCOS), clomifene, ovulation induction with gonadotrophins, metformin in PCOS
- • Tubal disease: salpingostomy or IVF
- • Endometriosis: surgical treatment, then IVF if needed
- • Male factor: lifestyle, varicocele repair, IUI for mild, ICSI for severe, surgical sperm retrieval in obstructive azoospermia
- • Assisted conception: IUI, IVF, ICSI; donor gametes or surrogacy where appropriate
- • Psychological support — strongly recommended throughout
Prevention
- • Avoid smoking and recreational drugs
- • Optimise BMI, manage chronic conditions early
- • Prompt treatment of STIs to prevent tubal damage
- • Fertility preservation before gonadotoxic treatment
Complications
- • Psychological distress, relationship strain
- • Ovarian hyperstimulation syndrome (OHSS) during IVF
- • Multiple pregnancy with assisted conception
- • Ectopic pregnancy (higher with tubal disease)
Prognosis
Most couples eventually achieve pregnancy. IVF live-birth rates per cycle are ~32% under 35, falling to ~5% over 42 with autologous oocytes; donor eggs offer good outcomes at older ages.
Education & self-care
Early assessment matters — especially if the female partner is over 35 or there is a known risk factor. Most causes have effective treatments.
Frequently asked questions
Whose 'fault' is infertility?
Neither partner's — about a third of cases are male, a third female, a third combined or unexplained.
Does the NHS fund IVF?
Eligibility varies by region. NICE recommends 3 full cycles for women under 40; many ICBs offer fewer.
Should I freeze my eggs?
Consider it before age 35 if delaying pregnancy. Discuss success rates and costs with a fertility clinic.