Infertility, an inevitability?

Nov 21, 2023

Infertility, although often perceived as a discouraging ordeal, is a complex reality that affects many couples wishing to expand their family. On average, the probability of achieving pregnancy during a month or menstrual cycle without using contraception is estimated at between 20 and 25%. However, in reality, one in eight couples seek medical advice due to difficulties in conceiving. 10% of them remain in this situation after two years of trying. These revealing figures highlight the prevalence of this problem.

The main causes of infertility

The cause of infertility can be male, female, or can result from both partners combined.

In women

Various pathologies can cause infertility. Here are the most common ones:

Polycystic ovary syndrome (PCOS), affecting about 10% of women, is responsible for a lack of ovulation in half of affected women.
Endometriosis , also affecting nearly 10% of women. In addition to the pain and discomfort caused by this pathology, it can induce alterations in the expression profile of follicular genes, an abnormality in the stock of ovarian follicles and disorders of embryonic implantation.
Ovarian failure is another significant cause of infertility. After the age of 35, it becomes the leading cause of infertility and cannot be corrected by medically assisted procreation, unless using egg donation. Women are born with a stock of follicles that diminishes over time. This explains why female fertility is optimal between the ages of 18 and 31, and declines beyond this age. Reproductive function becomes almost zero after the age of 45. Due to the increase in the average age at which women decide to have a child, more and more women are exposed to ovarian failure.
Bilateral tubal stenosis , marked by reduced patency of the fallopian tubes, blocks the passage of sperm to the egg. This condition, often linked to infections such as chlamydia, is the leading cause of infertility in many countries.

Other types of uterine abnormalities such as uterine malformations or fibroids can also cause infertility.

In men

First, testicular failure is one of the main causes of male infertility. Spermatogenesis abnormalities, which include quantitative and qualitative alterations of spermatozoa, represent frequent obstacles. There is a diversity of abnormalities, ranging from azoospermia (characterized by a total absence of spermatozoa) to oligospermia (marked by a very low number of spermatozoa), or teratospermia (involving morphological abnormalities of spermatozoa). However, it should be noted that the results of the tests used for the evaluation of these abnormalities do not always guarantee a reliable prognosis for the success of natural fertility or assisted reproductive technology (ART).

In addition, some sexual dysfunctions in men can also contribute significantly to infertility by impairing the ability to produce or deliver functional sperm during sexual intercourse. Various factors, such as vascular, hormonal, metabolic or neurological problems, can lead to sexual dysfunction, impacting the quality and quantity of sperm produced.

Causes common to both partners

Aside from the causes mentioned above, there are other reasons that can contribute to infertility in women, as well as in men. First, certain medical treatments , such as chemotherapy, can induce infertility by affecting sperm production in men or altering the quality of eggs in women. Environmental factors, such as smoking, can also play a role by negatively impacting sperm quality.

Psychological blockage and stress are also significant factors. A high level of stress at the time of fertilization is associated with a reduction of approximately 40% in the probability of fertilization in women. However, it is essential to check for the absence of underlying organic causes before concluding that stress is the cause.

Weight , in both men and women, can also influence fertility. Being overweight has been linked to fertility problems, highlighting the importance of a healthy lifestyle to promote conception.

In 10% and 25% of cases, however, infertility remains unexplained. This situation is characterized by the absence of an identified cause, despite in-depth clinical examinations of both partners, hormonal assessments and verification of fallopian tube patency in women, as well as sperm analysis in men.

Infertility pathway and management

When to worry?

It is generally recommended to consult in the absence of pregnancy after one to two years of regular sexual intercourse (two to three times a week) during favorable periods without contraception. However, this period may vary depending on the age of the woman and the medical data of the couple, which can potentially influence fertility. In certain situations, such as significant medical problems or advanced age, this first consultation may be considered earlier. Traditionally, the gynecologist is the first point of contact in this process, deciding on referral to a specialist or a center specializing in the management of infertility.

The first consultation

The first medical consultation has several objectives: to confirm the diagnosis of infertility by assessing its duration, to identify sometimes simple and modifiable causes (for example, gaps in the understanding of the processes of fertilization and periods of fertility), and to consider, after a medical examination of the couple, the necessary additional examinations. This consultation involves the participation of both members of the couple. At the same time, the doctor looks for factors that may influence fertility, whether in the man or the woman. A thorough clinical examination is generally carried out. Following this first consultation and depending on the conclusions, additional examinations may be prescribed, such as a blood test, an abdominopelvic ultrasound or a spermogram.

Thus, the first consultation often constitutes a preliminary step to the complete infertility assessment, allowing the doctor to gather essential information to guide the rest of the investigations and determine the specific tests required.

Therapeutic approaches to infertility

There are two distinct strategies for treating infertility: treating the underlying cause or working around the infertility problem. In the first case, when pathologies or metabolic disorders are identified, drug treatment may be recommended. For example, drugs may be used to stimulate ovulation to correct a failed ovulation. In addition, in situations where the cause of the reduced fertility is operable, surgery may be considered. This applies in particular to conditions such as endometriosis, certain malformations of the uterus or a uterine fibroid.

In the second case, Assisted Reproductive Technology (ART), formerly called medically assisted procreation (MAP), offers an alternative to overcome the challenges of conception without first treating the causes of infertility. The main objective of ART is to achieve pregnancy through in vitro manipulation methods. In Vitro Fertilization (IVF) is a flagship technique of ART, particularly effective in treating problems such as testicular insufficiency, which includes conditions such as teratospermia and oligospermia. These therapeutic approaches offer couples facing infertility options adapted to their specific situation.

Furthermore, various methods for the cryopreservation of gametes or the preservation of reproductive capacities are currently available. The possibility of preserving gametes without a direct link to an illness, with a view to postponing a pregnancy for personal reasons, is however not an authorised practice in France.

Non-drug tips to support fertility

Along with medical care, certain lifestyle changes can help support fertility. These include:

Weight management : Obesity reduces the chances of pregnancy, increases the risk of complications during pregnancy and impairs the results of in vitro fertilization. Excessive thinness in women is also harmful. It is therefore recommended to achieve or maintain a satisfactory weight.
Daily physical activity . Although women should avoid overly intense physical exercise, it is still advisable to practice regular physical activity.
Wearing suitable clothing . For men, avoiding wearing tight pants is recommended, in order to prevent an increase in testicular temperature which could harm sperm production.
Stress management : Given the direct impact of stress on fertility, reducing stress levels is essential.
Eat a balanced diet : Adopting a healthy diet is recommended, with particular attention to caffeine consumption, especially in women exceeding 5–6 cups per day, and in association with tobacco.
Avoid harmful substances : Minimizing exposure to pesticides and organochlorine pollutants is recommended.
Consider smoking cessation and drug cessation: smoking cessation in women is desirable, as smoking reduces natural fertility and can have negative effects during IVF. In men, smoking cessation is recommended before any medically assisted procreation. Similarly, stopping drug use, including cannabis, heroin, cocaine and hallucinogens, is essential.
Use natural treatments : Some natural herbal supplements can support fertility in both women and men.

In summary, infertility management remains a case-by-case approach, requiring a holistic approach that takes into account various medical, psychological, and environmental aspects. Current research continues to explore new factors and mechanisms, opening the way to promising potential treatments.