Chapter 8 – Fertility Problems
Summary of chapter
Female fertility (or fecundity) is a woman’s reproductive capacity, the ability to conceive and bear a child. In normal circumstances a woman is at their most fertile in youth and their fertility declines with age. Fertility appears to decline from the late 20s onwards, with women aged 35-39 years being half as fertile as women aged 19-26 years. Around 75 per cent of women who attempt conception at age 30 will have become pregnant and had a live birth within a year, 66 per cent at age 35 and 44 per cent at age 40.(1)
Couples may benefit from advice on maximising their natural fertility. Important lifestyle advice includes starting a family in your 20’s or early 30’s, having a healthy diet, being in a healthy weight range, and avoidance of tobacco, alcohol and other non-prescribed drugs.
Couples may need education about the optimal times in the cycle for intercourse, however it is important to counsel couples that intercourse must be frequent and not just on the day of ovulation. For more information, see Your Fertility website.
Infertility is the absolute inability to conceive or carry a baby to term. It is defined as ‘primary’ in couples who have never conceived and ‘secondary’ in couples who have conceived in the past.
In Australia a couple is generally regarded as experiencing infertility if, after regular sexual intercourse, they have not conceived in one year.
In 2016, 81,062 ART treatment cycles were attempted in Australia and New Zealand.(18) There were 14,515 live babies born (17.9 percent per initiated cycle in women of all ages).(18) Treatment options include: Intrauterine insemination (IUI), invitro fertilisation (IVF) Intracytoplasmic sperm injection (ICSI) and frozen embryo transfer. Gametes may be autologous or donor. Donor eggs or sperm may be used in Australia when required.
In female same sex relationships, depending on their personal circumstances, it may be appropriate to investigate both female partners to ascertain which partner in the relationship may have the higher chance of a successful pregnancy. Fertility assessment is as detailed above and investigations are guided by history and examination.
Women in same sex relationships will need to obtain donated sperm in order to be able to conceive.
Sperm donation
Donor sperm may be required by heterosexual couples with male factor infertility, single women and by female couples in same sex relationships who wish to become parents. Sperm donors may be known to the patient or can be sourced for intrauterine insemination or IVF through some fertility clinics.
All gamete donations must be altruistic with payment prohibited by law, however expenses can be reimbursed. All children born from donor gametes have the legal right to information about their origins, therefore the sperm donor must consent to providing details which are stored on a register.(21) The donor does not become the legal father of the offspring and there are limits placed on the maximum amount of children that a sperm donor can father (including his own children) to reduce the risk of inadvertent future
A surrogate is a person who gives birth to a child on behalf of another person. The surrogate or gestational carrier conceives via IVF often with eggs, sperm or embryos from the commissioning couple. They carry the pregnancy, give birth to the child then surrenders parental rights to the third party. The services of a surrogate may be required by a heterosexual couple or same sex couple when the female is unable to carry a pregnancy, or a male couple who wish to become parents. IVF clinics have specific legal, medical and social criteria which need to be met for the parson to act as a surrogate.
In most Australian states altruistic surrogacy is legal; however commercial surrogacy where a fee is charged or paid is illegal. Expenses for medical care and other reasonable expenses can be legally reimbursed. It is illegal to advertise for a female surrogate or for a person to advertise such a service. The surrogate’s own eggs can be used but it is more usual for the oocyte to come from an egg donor, then the surrogate does not have a genetic link to the offspring. Information on oocyte donation can be found at the websites listed in the
Transgender couples desiring fertility treatment should be referred for expert advice. Depending on their circumstances, they may be able to provide their own gametes or may require donor eggs or sperm.
It is important to be aware that the experience of the investigations and treatment for subfertility is likely to produce stress in the relationship due to:(2)
invasion of the couple’s ‘intimate privacy’ the demands of the process with repeated and often painful procedures possible family and cultural pressures from those who are not aware that there may be a problem conceiving a feeling of isolation from their ‘fertile’ friends and resentment when others seem to be achieving pregnancies easily possible sexual difficulties as intercourse becomes ‘goal oriented’ the difficult decision-making process when it comes to whether to continue or to stop treatmentsThe primary care clinician can assist a couple in this area by:(2)
helping them sort out the facts from the myths around fertility providing supportive counselling to clarify fears and expectations referring to an expert fertility counsellor addressing issues of ‘blame’ if a problem is identified in one person; subfertility is a ‘couple issue’ explaining the usual course of investigations and the time delays outlining possible options for treatment giving accurate information on prognosis, particularly in women of advanced ageFamily Planning NSW fact sheet:
Maximising natural fertility InfertilityAccess Australia – A consumer controlled, independent sector organisation
Fertility Society of Australia – This site includes a list of all accredited ART units in Australia by state
NSW Health
Assisted Reproductive Technology information on all aspects of assisted reproductive technology including links to interstate information: Assisted Reproductive Technology Central RegisterIVF Predict – Fertility calculator
Baird D, Collins J, Egozcue J, Evers LH, Gianaroli L, Leridon H, et al. Fertility and ageing. Human Reproduction Update 2005;11(3):261-76. National Institute for Health and Care Excellence (NICE). Fertility problems: Assessment and Treatment. Clinical Guideline 156. [Internet]. 2013 [cited 15 September 2015 ]. Available from: https://www.nice.org.uk/guidance/cg156/resources/fertility-problems-assessment-and-treatment-pdf-35109634660549. Department of Health and Social Care. Expert Group on Commissioning NHS Infertility Provision – Regulated Fertility Services: A Commissioning Aid. [Internet]. United Kingdom Government; 2009 [updated 2009 June 18]. Poppe K, Velkeniers B, Glinoert D. Thyroid disease and female reproduction Clinical Endocrinology 2007;66(3):309-21. Vil aL, Velasco I, González S, Morales F, Sánchez E, Torrejón S, et al. Controversies in endocrinology: On the need for universal thyroid screening in pregnant women. European Journal of Endocrinology 2013;170(1):R17-30. van den Boogaard E, Vissenberg R, Land JA, van Wely M, van der Post JA, Goddijn M, Bisschop PH. Significance of (sub)clinical thyroid dysfunction and thyroid autoimmunity before conception and in early pregnancy: a systematic review. Human Reproduction Update. 2011;17(5):605-19. Pilsgaard F, Grynneru A, Lossl K, Bungum L, Pinborg A. The use of anti-Mullerian hormone for controlled ovarian stimulation in assisted reproductive technology, fertility assessment and -counselling. AOGS. 2018;97:1105-13. Tal R, Seifer DB, Wantman E, Baker