There are actually two types of infertility:

• Primary infertility:
  You and your partner have never conceived before and have been trying for 12 months.
• Secondary infertility:
  You and your partner have conceived in the past but are unable to conceive again, despite trying for 12 months.

How common is it?
Infertility is a lot more common than you'd think. The latest research suggests that between one in seven and one in six couples are affected by infertility at some time during their reproductive lives.

What's the difference between infertility and sub-fertility?
Being infertile no longer means that you'll certainly never be able to have a child. Significant advances in fertility treatment over the past twenty years means that many couples who would once have remained childless now have a good chance of conceiving. So doctors now prefer to call a failure to conceive naturally, 'sub-fertility', because it's more accurate.

Sub-fertility means that although natural fertility is reduced, the problem may be overcome with medical assistance.

Natural Fertility:
Even if you don't have any fertility problems, getting pregnant isn't as easy as you'd think. That's because there are only a few days in each month when you can conceive. For a young healthy couple with no identifiable fertility problems the chance of conceiving per month (i.e. per menstrual cycle) is about 20 per cent. On average, it takes a healthy couple just over five months to conceive their first pregnancy.

But the older you get, the harder it is to conceive. Your chances of conceiving each month decline slowly from the age of 30 and more rapidly from about the age of 38. So, by the time you're 40, you're chances of conceiving are only about five per cent per month. The time it will take you to conceive also increases.

What are the causes of infertility?

Female age:
There are a number of causes of reduced fertility, but the single biggest influence is female age. The age of the male partner age has very little impact on fertility (because sperm is produced continually).
Female fertility is halved above the age of 35 and continues to decline. This natural reduction in fertility not only has an impact on the ability of a couple to conceive naturally but also on the success rates of fertility treatments.

Why does a woman's age affect her fertility?
The simple explanation is this: her eggs get older. Every woman is born with a set number of eggs in her ovaries. Every month, from puberty, a number of these eggs are recruited and one is selected to be released at ovulation, in the middle of the menstrual cycle. The others simply die. But once a woman gets to 35, the eggs that remain in her ovary are not of as high quality as they were say 10 years previously. These eggs are less likely to be fertilised and, if fertilised, less likely to form a viable pregnancy.

Having older, lower quality eggs is also the main reason why women over 35 are more likely to miscarry and are more at risk of having a baby with Downs syndrome pregnancy.

2) Why else might I be infertile?
There are several potential causes:

• Problems with ovulation
  This accounts for around 25-30 per cent of causes and includes problems such as Polycystic Ovarian Syndrome (PCOS) and Premature Ovarian Failure (POF).
  
  
• Tubal problems
  Damage or blockage of the Fallopian tubes will interfere with, or prevent, the sperm and egg meeting. Tubes can be blocked or damaged as a result of previous infection in the pelvis (as a result of STDs) or as a consequence of severe Endometriosis. Around 15-20 per cent of couples will have tubal problems.

3) Male factor problems
In 30 per cent of infertility cases, the male partner will have a problem. These include: reduced or absent sperm (when little or no sperm is produced) and abnormalities in the motility (movement) and appearance of sperm.

4) Unexplained
Frustratingly, in around 20 per cent of couples fertility investigations will not discover an obvious cause. Patients with mild Endometriosis are often included in this category.

5) Miscellaneous causes
Occasionally problems related to intercourse itself - either physical or psychological - may be the cause of reduced fertility. These include male impotence, the inability to achieve effective penetration, or vaginismus (when the vaginal muscles contract, preventing penetration). In some circumstances mucus produced by the cervix may be hostile to sperm, preventing it from reaching the egg.

Multiple Problems
It's worth noting that in around 20% of couples more than one problem may
be identified.

When should I seek help?
Most couples should consider seeking help after one year of attempting to conceive without success. But, if the female partner is over the age of 35 the couple shouldn't delay: if they haven't conceived within six months, they should ask their doctor to refer them for fertility investigations.

How will I find out why my partner and I can't conceive?
There are four major investigations which are routinely performed to help identify a cause or causes for reduced fertility, three for women and one for men.

• Hormonal testing
  The woman has a blood test around day three of her period. This measures levels of a hormone called Follicle Stimulating Hormone (FSH) in her bloodstream, indicating how the ovaries are functioning. A high level of FSH implies reduced fertility and often a reduced chance of fertility treatment success.
  
  Occasionally she may have other blood tests to check the levels of other reproductive hormones.
  
  
• Pelvic Ultrasound
  This test allows a doctor to examine a woman's internal reproductive organs, her uterus and ovaries, providing valuable information about her natural fertility.
  
  It must be performed around day 10 of the menstrual cycle.
  
  A specially-designed probe is placed within the vagina, allowing the doctor to observe the woman's internal organs on a screen.
  
  Advanced scanning with 3D ultrasound and Doppler technology(assessment of blood flow) can give additional and detailed information.
  
  
• Tubal Patency test
  This shows whether a woman's fallopian tubes are damaged or blocked.
  Dye is injected via the vagina into the uterus. The dye should then flow into the tubes and eventually into the abdomen itself. The doctor uses X-ray pictures to see if the dye spills freely from the tubes (this is called a hysterosalpingogram or HSG for short). The same investigation can be done using an ultrasound scan (Hycosy) or when a laparoscopy (a key-hole surgical procedure used often to investigate reduced fertility) is performed.

3) Semen Analysis
This is a simple test which analyses the male partner's sperm, checking the number, movement and amount of normal appearing sperm. After three days of abstinence from sex and masturbation, the man produces a semen sample by masturbating into a sterile container. This sample should be analysed within two hours. Should an abnormal result be found, the first step is usually to repeat the semen analysis to ensure the result is accurate.

Once these basic investigations have been performed, most of the leading causes of reduced fertility should be identified. Occasionally, further investigations may be required to help discover the problem.

I'm infertile - will I ever have a baby?
Don't give up hope. Over the last 20 years the advances in fertility treatments have been truly astounding. It is now possible to offer hope to couples who previously would have had a negligible chance of becoming pregnant.

How do I know which treatment to try?
Not all fertility treatments are suitable for all patients. Several factors must be considered before a particular treatment is followed, to guarantee the best chance of success. These include:

• the age of the female partner
  
• how long you and your partner have been trying to conceive
  
• whether there is any identifiable cause for reduced fertility

What are the most commonly used fertility treatments?

1) Ovulation Induction
This is the simplest form of fertility treatment and is used when a woman isn't ovulating and in some cases of unexplained infertility.

First, the female partner takes a short course of tablets (usually clomid) in the early part of her menstrual cycle. These tablets are designed to induce ovulation.

In the middle of her menstrual cycle, she then has a pelvic scan to see how many eggs have been produced. As with most fertility treatments, more than one egg may be released so the risk of twins or triplets is increased.

Often, an injection is given at the appropriate time to induce ovulation. Following this injection, the couple are instructed to have intercourse.

There is around a 10-15% chance of falling pregnant using this treatment.

2) Intrauterine Insemination (IUI)
This is similar to ovulation induction except, instead of natural intercourse, the female partner is inseminated with sperm - either her partner's or that of a donor. This treatment is mainly used in couples with unexplained infertility or mild male factor problems.

At the time of ovulation, a prepared sample of sperm is injected into the cavity of the uterus via the vagina. Success rates vary from 10-to-20%.

3) In-Vitro fertilisation (IVF)
This is also known as 'test tube babies'. It was introduced as a method of treating infertility due to blocked tubes but is now used for many other fertility problems, including moderate to severe male factor problems and unexplained infertility (when simpler treatments haven't worked). It's often used in cases where the female partner is aged 40 or over.

First, the female partner is given a course of powerful hormonal injections to stimulate her ovaries to produce many eggs (on average around 10). When ready, the eggs are collected from the ovary during a short procedure. The eggs are fertilised in the laboratory with her partner's sperm (or donor sperm). Any embryos which result are then left to grow for two or three days. Either one, two or three of the best embryos are then replaced in the cavity of the womb. Any remaining embryos can be frozen and replaced at a later date.

Pregnancy rates are as high as 30% using IVF, but your chances of getting pregnant are strongly influenced by the cause of infertility and female age (there's only a 10 per cent pregnancy rate in women over 40)

4) Natural Cycle IVF
IVF can be performed in cycles without ovarian stimulation.

5) Intracytoplasmic sperm injection (ICSI)
This is used in cases of severe male factor problems (i.e when very little sperm is being produced). It's similar to IVF except each egg is directly injected with an individual sperm to achieve fertilisation. If a man is producing no sperm in his semen at all, doctors are sometimes able to gather sperm directly from his testicles and then perform ICSI.

6) Egg donation:
This technique is used in women who are menopausal (as a result of surgery, chemotherapy or radiation treatment or due to premature ovarian failure) or woman who have reduced natural fertility due to age or hormone problems. It can also be used in women who have tried IVF without success, where an egg-problem may be suspected.

It involves the use of a donated egg or eggs, which are fertilised with the male partner's sperm. The resulting embryo or embryos are then replaced into the uterine cavity.

Egg donors can be known or anonymous and, ideally, should be under 35 and have already had children of their own. The donor needs to undergo an IVF cycle (see IVF, above).

The recipient is given hormone injections to make sure that the lining of her womb is ready for the replacement of the embryo.

Egg donation has a pregnancy rate of around 30%.

7) Other techniques
Occasionally, other techniques are used. For example, some women with blocked tubes may benefit from tubal surgery, but in general IVF gives a better chance of conceiving overall.

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