Fertility and Infertility

Fertility refers to the ability to get pregnant (“conceive”). The time it takes to get pregnant can vary considerably and will depend on a variety of factors.

Over 80% of couples will get pregnant within 1 year if they have regular unprotected sex (sexual intercourse every 2 to 3 days without using contraception) and more than 90% of couples will get pregnant naturally within 2 years.

Around 1 in 7 couples may have trouble getting pregnant.

You do not need to time having sex only around ovulation. Having vaginal sexual intercourse every 2 to 3 days will give you the best chance of getting pregnant.

It is important for couples to try and keep sex enjoyable by concentrating on each other and their relationship, rather than worrying about conceiving. This will help to limit stress.

Fertility

Lifestyle & fertility

When you are trying to conceive there are several life-style considerations that can improve your chances of a successful pregnancy.

  • Have regular intercourse. It is recommended that you have intercourse every 1-3 days. If you have regular periods, it is highly likely that you are releasing an egg most months. Ideally the sperm need to be in the woman’s pelvis before the egg is released hence the recommendation to have intercourse every 1-3 days throughout the cycle. If you only have intercourse when you think you are ovulating (detected via an ovulation kit or app), then you may miss this window. Additionally, long abstinence periods in the man (longer than a week) tend to lead to semen samples with reduced motility. If your periods are irregular or you have a very long cycle you should see your GP to discuss whether earlier investigations or referral to the fertility clinic is indicated.
  • Do not smoke. Smoking ages your ovaries and your eggs and is linked to lower fertility. In addition, all Clinical Commissioning Groups (CCGs) restrict NHS funded treatments to non-smokers.
  • Cut down on alcohol. Heavy drinking is linked to lower fertility. Women should limit alcohol consumption to 1-2 units per week and men to 4 units per week when trying to conceive.
  • Stay active. Being moderately active has been shown to help with fertility.
  • Men should avoid situations where scrotum temperature could be raised (e.g., saunas, hot baths, seat warmers, tight underwear). Your testicles lie outside your body because, to produce the best quality sperm, they need to be kept cooler than the rest of you. If you are planning a pregnancy, wear loose-fitting underwear, such as boxer shorts as well as taking a few simple measures to keep your testicles cool. For example, if your job involves working in a hot environment, take regular breaks outside. If you sit still for extended periods, get up and move around regularly.
  • Maintain a healthy weight. Ideally your body mass index (BMI) should be in the normal range 19-25. NICE guidance states that being overweight (BMI 25-30) is not a problem but there is good evidence that being underweight (BMI <19) or “obese” (BMI>30) reduces the chance of a live birth. Please be aware that NHS funding is restricted, and all Clinical Commissioning Groups (CCGs) have rules about BMI for the women and for some CCGs for the men too.
  • All women are advised to take pre-conception folic acid at a dose of 400 mcg daily from the time that they start trying for a pregnancy until the end of the first trimester (12 weeks). This is to reduce the risk of the baby developing neural tube defects (NTD) such as spina bifida (the dose should be increased to 5mg daily for women at high risk of NTD).
  • Consider Vitamin D supplements. Some studies have shown that vitamin D deficiency reduces the chance of getting pregnant. Most people in the UK are vitamin D deficient in the winter months due to lack of sunlight, so it is very reasonable to buy over-the-counter vitamin D tablets (10mcg) when trying to get pregnant.
  • Review existing medication. If either of you are receiving regular treatment with prescribed medication you should discuss this with your GP to ensure that your medical condition is well controlled and that the drugs you are taking are safe for pregnancy.
  • Try to minimise stress & anxiety. It is very common to feel stressed or become anxious when you are trying to get pregnant, and it is not happening. It may be worth discussing this with your GP or you can access patient support groups.  Some couples do have good support from their friends and family, but other couples prefer to keep their concerns confidential and private. What is most important is for you to decide, as a couple, what works best for you.
  • Use the internet wisely. It is empowering to find out information about getting pregnant and the possible investigations and treatments, but it is strongly recommended that you access recognised UK bodies for advice and information such as the Human Fertilisation and Embryology Authority or NHS UK or NICE Guidance. Information on the internet may not be evidence based, may represent someone’s personal views or may be relevant to a different country where the law and regulations are different from the UK.

The following are NOT recommended by NICE due to lack of evidence:

  • Complementary therapies
  • The use of basal body temperature charts to predict ovulation

Contraception & fertility

Most women use contraception as a safe way to avoid getting pregnant when they are not ready for children. When you stop contraception, it is often because you would like to try for a baby.

If you have been taking contraception that uses hormones (such as the Pill, the patch, injections) for a long time, you may not know your cycle very well (for example how long it is). This is because the bleed that happens when you move to a new packet of the Pill is not a true period. A true period happens when you ovulate (release an egg from your ovaries) and the Pill prevents ovulation.

If you have stopped taking contraceptives that were based on hormones your periods may be a bit irregular (come at different times of the month) for the first few months while your body gets used to the change in hormone levels.

The Pill does not cause infertility, but it may cover up conditions that are linked to infertility because lack of periods is a sign of ovulation problems, endometriosis, or polycystic ovary syndrome (PCOS). If you do not have periods anyway, these problems may be missed until you come off contraception.

Infertility

Infertility is when a couple cannot get pregnant (conceive) despite having regular unprotected sexual intercourse (defined as no less than twice weekly).

Unexplained infertility is defined as failure to conceive after 2 years regular intercourse in the absence of reproductive pathology. However, the term sub-fertility is often applied after 1 year of failing to conceive naturally.

In Devon, infertility investigations and/or treatment would normally be considered when an otherwise healthy couple has failed to conceive after 1 year of regular, unprotected intercourse.

Earlier intervention may be appropriate where there is a clinical basis to suspect an underlying fertility problem.

For couples who have been trying to conceive for more than 3 years without success, the likelihood of getting pregnant naturally within the next year is 1 in 4, or less.

Infertility affects about 1 in 7 couples in the United Kingdom.

There are 2 types of infertility:

  • primary infertility – where someone who is never conceived a child in the past has difficulty conceiving.
  • secondary infertility – where someone has had 1 or more pregnancies in the past but is having difficulty conceiving again.

Read more about how infertility is diagnosed.

Causes of infertility

There are many possible causes of infertility, and fertility problems can affect either partner. But in a quarter of cases, it is not possible to identify the cause.

Common causes of infertility include:

  • lack of regular ovulation (the monthly release of an egg)
  • poor quality semen
  • blocked or damaged fallopian tubes
    endometriosis – where tissue that behaves like the lining of the womb (the endometrium) is found outside the womb

Risk factors for infertility

There are also several factors that can affect fertility. These include:

  • Age – fertility declines with age
  • Weight – being overweight or obese (having a BMI of 30 or over) reduces fertility; in women, being overweight or severely underweight can affect ovulation.
  • Sexually transmitted infections (STIs) – several STIs, including chlamydia, can affect fertility.
  • Smoking – can affect fertility: smoking (including passive smoking) affects your chance of conceiving and can reduce semen quality; read more about quitting smoking.
  • Alcohol – the safest approach is not to drink alcohol at all to keep risks to your baby to a minimum. Drinking too much alcohol can also affect the quality of sperm (the chief medical officers for the UK recommend adults should drink no more than 14 units of alcohol a week, which should be spread evenly over 3 days or more).
  • Environmental factors – exposure to certain pesticides, solvents and metals has been shown to affect fertility, particularly in men.
  • Stress – can affect your relationship with your partner and cause a loss of sex drive; in severe cases, stress may also affect ovulation and sperm production.

When to seek medical help for infertility

You should consider consulting your GP if you are a woman of reproductive age and have not conceived after 1 year of regular, unprotected vaginal sexual intercourse.

You should see a GP sooner if:

  • You are female and are aged 35 or over (a decline in fertility speeds up when reaching your mid-30s).
  • You have known infertility or a history of predisposing factors for infertility (e.g. Pelvic inflammatory disease or undescended testes)

It is always best for both partners to visit the GP as fertility problems can affect either or both partners.

Same-sex couples

Access to NHS funded investigation in Devon is commissioned in same-sex couples once subfertility has been established.

Female Same-Sex Couples:
  • Failure to conceive after 6 privately funded cycles of artificial insemination within the past 12 months (in the absence of any known cause of infertility)
Male Same-Sex Couples:
  • Failure to conceive after 6 privately funded cycles of artificial insemination within the past 12 months (in the absence of any known cause of infertility)

or

  • 12 months with vaginal intercourse (in the absence of any known cause of infertility).

What to expect when you consult your GP

Your GP will be able to do an initial assessment to check for things that may be causing your fertility problems and advise you about what to do next.

This will include:

  • A full lifestyle and sexual history and examination (including MMR vaccination history, BMI etc)
  • Women – Blood tests on two occasions (7 days before your period and 1-5 days after your period)
  • Men – Semen analysis (if this is abnormal then a second specimen will be required after a minimum of 6 weeks)

Once all the results and required information is available then your GP will discuss these with you before considering a specialist referral using a standard proforma.

Treatments for infertility

Fertility treatments include:

  • Medical (drug) treatment to stimulate the release of eggs from the ovary (used for lack of regular ovulation)
  • Surgical treatment to improve the chances of an egg meeting a sperm in a receptive womb. Includes treatment for endometriosis, repair of the fallopian tubes, or removal of scarring (adhesions) within the womb or abdominal cavity.
  • Assisted Reproductive Techniques also known as Assisted Conception (any treatment that deals with a means of conception other than vaginal intercourse). Includes:
  • Surrogacy This is when a woman agrees to become pregnant and give birth to a child for someone else who will then become the parent(s) of the child.

Funding for surrogacy is only available in Devon if it is required due to either of the following;

  • Congenital absence of the uterus
  • Malignancy

Funding is NOT available for finding a suitable surrogate.

It is important to understand that some treatments for infertility, such as IVF, can cause complications. For example:

  • Multiple pregnancy – if more than 1 embryo is placed in the womb as part of IVF treatment there is an increased chance of having twins; this may not seem like a bad thing, but it significantly increases the risk of complications for you and your babies.
  • Ectopic pregnancy – the risk of having an ectopic pregnancy is slightly increased if you have IVF

Specialist referral

The investigation of and treatments for infertility under the NHS are subject to local commissioning criteria and will only be accepted for NHS funding by NHS Devon when the relevant criteria are met.

Private treatment is also available, but it can be expensive and there is no guarantee it will be successful. It is important to choose a clinic that is licensed by the Human Fertilisation and Embryology Authority (HFEA).

Under local commissioning policy, most couples experiencing problems with conception will be entitled to an initial consultation with a specialist fertility service to discuss what investigations and treatments are available to them. This includes same sex couples in whom subfertility has been established (see above: “when to seek help for infertility”).

Referrals to specialist services are made through your GP who is required to perform a series of preliminary investigations and include the results of these with the referral. These will include at least 1 semen analysis for the male partner and a series of blood test results for the female partner together with details of the couples smoking habits, age, BMI’s, and reproductive history (please see separate section for details regarding same sex couples).

Please note, your referral may be returned to your GP if you do not meet the referral criteria or there are details missing on your GPs referral letter.

The following groups of patients are NOT entitled to initial consultation at the hospital, investigation, or treatment under local commissioning policy:

1. Individuals concerned about current or future fertility who have not been trying to conceive for the requisite time of 12 months.

Exceptions to this when an early referral is recommended are:

i) Woman is 36 years or over; requisite time is reduced to 6 months (this is because female fertility reduces with age)

ii) Known cause of infertility

Anovulation (no egg release):

  • Irregular cycles (cycles frequently outside 26-36 days)
  • Complete lack of periods
  • Luteal progesterone <30 (from blood test results)

Tubal disease risk factors (e.g. previous chlamydia, pelvic inflammatory disease, ectopic pregnancy, abdominal-pelvic surgery, endometriosis)

A history of predisposing factors (e.g., undescended testes, prior treatment for cancer)

Sperm dysfunction (on two separate semen tests)

Problems in your pelvis, identified on ultrasound scan.

iii) Meet the local criteria for cryopreservation

2. Previous sterilisation in either partner (even if it has been reversed)

3. Couples who have already had NHS funded assisted conception treatment including intrauterine insemination (IUI), in vitro fertilisation (IVF), intracytoplasmic sperm injection (ICSI) and donor insemination (DI).

All other patients are entitled to initial consultation if they meet criteria for referral outlined below but will only be offered NHS treatment if eligible according to the NHS Devon Policy: Assisted Conception

If deemed eligible, you will be offered a choice of hospital to receive your treatment, but it is worth noting that you are unable to change this choice once treatment has been started.

Same-sex couples

If a same-sex couple has a diagnosed fertility problem on investigation, then their sub-fertility will be treated.

However, NHS funding will NOT be available:

  • for donor sperm for female same-sex couples
  • or surrogacy arrangements for male same-sex couples.

This is on the basis that unless they are medically sub-fertile their childlessness is due to the absence of gametes (sperm or eggs) of the opposite sex.

Where the circumstances of an individual patient do not meet the criteria described above, exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient’s GP, consultant, or clinician. Applications cannot be considered from patients personally.

Specialist investigations

Ultrasound scan:

An ultrasound scan can be used to check your ovaries, womb (uterus) and fallopian tubes. Certain conditions that can affect the womb, such as endometriosis and fibroids, can prevent pregnancy.

Ovarian Reserve Testing:

Ovarian Reserve Testing is a combination of blood tests and an ultrasound scan to estimate a woman’s ‘ovarian reserve’. In other words, this can be thought of as an ‘egg count’.

There are specific reasons why an ‘egg count’ is a useful test for fertility treatments. For example, the tests can help to determine if a woman is close to the menopause or if there are other conditions that could affect fertility e.g., PCOS (Polycystic Ovarian Syndrome)

However, it is important to note that the tests do not give information on egg quality. Egg quality reduces with age and is the main reason that fertility also declines with age.

Tubal Patency Testing:

Blockage or adhesions of the Fallopian tubes affect up to a third of women experiencing a delay in getting pregnant. There are three ways of checking whether a woman’s fallopian tubes are open (patent):

  • A laparoscopy and dye test (“lap & dye test”)

Keyhole surgery used to exclude an obstruction of the eggs passage – for example, if you have had an episode of pelvic inflammatory disease in the past, or if scans suggest a possible blockage of one or both of your tubes. Laparoscopy involves making a small cut in your lower tummy so that a thin tube with a camera at the end (a laparoscope) can be inserted to examine your womb, fallopian tubes, and ovaries. Dye is then be injected into your fallopian tubes through your cervix to highlight any blockages in them.

  • A Hysterosalpingogram (HSG). A hysterosalpingogram is an X-ray of your womb and fallopian tubes after a special dye has been injected.

It can be used to find blockages in your fallopian tubes, which may be stopping eggs travelling along the tubes and into your womb.

  • Hysterosalpingo-contrast-ultrasonography (HyCoSy scan).

A special type of ultrasound scan sometimes used to check the fallopian tubes. A small amount of fluid is injected into your womb through a tube put into the neck of your womb (the cervix). Ultrasound is used to look at the fluid as it passes through the fallopian tubes to check for any blockages or abnormalities.

Assisted Conception

Under both local and national guidance, assisted conception is only available under the NHS when certain clinical criteria are met:

  • Age – Restricted to women aged up to 40 years.
  • Weight – Women must have a BMI (body mass index) of more than 19 and less than 30; Men must have a BMI of less than 30.
  • Smoking – Both partners should be objectively confirmed non-smokers. (Nicotine Replacement Therapies and Electronic Cigarettes will not be excluded from NHS treatment).
  • Welfare of the child – The welfare of any resulting children is paramount. There is a requirement for a recorded assessment confirming that the social circumstances of the family unit have been considered within the context of the assessment of the welfare of the child. This will include consideration of factors such as parental smoking, alcohol, and recreational drug use.
  • Previous children –
  • There should be no living children from the current relationship

and

  • At least one partner must have no living children from previous relationships

(This includes biological and legally adopted children and offspring who are adults).

  • Relationship Status – You are required to be in a couple for treatment to be deemed appropriate. A couple is defined as two people who are spouses or civil partners or cohabiting as partners in a financially interdependent relationship.
  • Previous assisted conception – The couple has not previously received NHS-funded assisted reproduction techniques. This applies unless failure of NHS-funded IUI is required to access IVF.

N.B. Couples should be aware that although they may meet eligibility criteria for treatment, their Consultant may decide that it is not clinically appropriate for them to receive assisted reproduction.

Cryopreservation to Preserve Fertility

Cryopreservation is a technique used to preserve fertility by freezing gametes (eggs or sperm) or embryos (fertilized eggs) prior to a treatment which may make a patient permanently infertile.

When can this used/what are the referral criteria?

Patients aged 39 years and younger who are:

  • about to start treatments, for example chemotherapy for cancer or radical surgery, where there is a significant likelihood of making a patient permanently infertile as an unwanted effect of treatment.

or

  • about to start gonadotoxic or teratogenic treatment which is likely to continue for their reproductive life and in whom stopping treatment for a prolonged period of time, to enable conception, is not an option.
When can’t this be used/who isn’t eligible?
  • Individuals who have previously been sterilised, even if sterilisation has been reversed.
  • Individuals who wish to delay conception and do not meet criteria for routine funding. This includes requests for cryopreservation of gametes and embryos for personal lifestyle reasons and concerns over future fertility (e.g., low ovarian reserve).

Requests for storage of gametes or embryos under circumstances which are not routinely funded require an application for exceptional funding to be made by the patient’s clinician (GP or hospital doctor) to the CCGs’ Individual Funding Request Panel.

How long will they be stored?

Storage of gametes and embryos will be funded for an initial period of five years for patients aged 39 years and younger.

Storage will be renewed in cases where the patient is prematurely infertile, is likely to have become prematurely infertile, or is receiving teratogenic treatment. Storage will be renewed in further five-year periods until the patient’s 40th birthday.

Funding for storage will cease twelve months following the death of the patient.

What happens next?

Once an individual is fit and able to proceed with Assisted Conception using their frozen gametes or embryos, they must meet the eligibility criteria for Assisted Conception in force at that time.

The funding of cryopreservation does not automatically entitle people to funding for Assisted Conception.

Waiting for a specialist opinion

If you have been referred for a specialist opinion your details will be reviewed, and it may be recommended that you are seen by a hospital clinician. Information to support you in choosing your preferred hospital, including waiting times can be found below.

How long will I wait?

If a hospital assessment and/or treatment is clinically recommended you will be referred for to a specialist. Click below to find out more about waiting times for routine hospital assessment and/or treatment.

Useful links

Fertility Exeter offers a series of downloadable .pdf patient information leaflets covering the following topics:

Diagnostic tests, Intrauterine insemination (IUI), In-vitro fertilisation (IVF), Sperm banking, Egg donation, Donor sperm treatment.