Infertility - Description, Causes and Treatment

What is Infertility ?

Infertility is the inability of a couple to achieve pregnancy after regular, unprotected sexual intercourse.

• For most couples, infertility is defined as no pregnancy after 12 months of trying.
• If the woman is 35 years or older, evaluation is usually started after 6 months of trying because fertility declines with age.

Types of infertility

How common is it?

• About 10–15% of couples experience infertility at some point.
• Causes may be related to the male partner, female partner, both partners, or remain unexplained.

Causes of infertility

Female causes

1. Ovulation disorders (most common)

The ovaries do not release an egg regularly.

Examples

• Polycystic Ovary Syndrome (PCOS)
• Thyroid disorders
• High prolactin levels
• Premature ovarian insufficiency

Clues: Irregular periods, absent periods, acne, excess facial hair.

2. Fallopian tube blockage

Egg and sperm cannot meet.

Causes

• Pelvic inflammatory disease (PID)
• Tuberculosis (important in India)
• Previous ectopic pregnancy
• Pelvic or abdominal surgery

3. Endometriosis

Tissue similar to the uterine lining grows outside the uterus, causing inflammation and scarring.

Symptoms: Painful periods, pelvic pain, pain during intercourse.

4. Uterine problems

• Fibroids, especially those distorting the cavity
• Polyps
• Congenital uterine abnormalities
• Intrauterine adhesions (Asherman syndrome)

5. Age-related decline in fertility

Female fertility decreases after 30 years and more rapidly after 35 years because egg number and quality decline.

6. Lifestyle and medical factors

• Obesity or being underweight
• Smoking, alcohol, drugs
• Excessive exercise
• Diabetes, autoimmune disease, chemotherapy, radiation

Male causes

1. Sperm production problems

• Low sperm count (oligospermia)
• No sperm (azoospermia)
• Poor motility
• Abnormal shape

2. Varicocele

Enlarged veins around the testes can impair sperm production.

3. Hormonal disorders

Low testosterone or pituitary hormone problems.

4. Blockage in sperm transport

After infection, surgery, or congenital absence of the vas deferens.

5. Sexual problems

• Erectile dysfunction
• Ejaculation disorders
• Retrograde ejaculation

6. Lifestyle factors

• Smoking
• Excess alcohol
• Obesity
• Anabolic steroids
• Heat exposure (sauna, hot baths, laptops on lap for long periods)
• Certain medicines and toxins

Combined and unexplained infertility

Unexplained infertility accounts for roughly 10–20% of cases.

Symptoms of infertility

Many couples have no symptoms except inability to conceive.

Main symptom

• No pregnancy after regular unprotected intercourse.

Symptoms in women

Symptoms in men

Red flags — seek medical evaluation early

• Woman ≥35 years trying for 6 months without pregnancy.
• Absent periods for 3 months or more.
• History of PID, genital tuberculosis, ectopic pregnancy, or pelvic surgery.
• Recurrent miscarriages.
• Known low sperm count or testicular disease.
• Cancer treatment in either partner.

Quick comparison

Female clues

• Irregular periods
• Painful periods
• Pelvic pain
• PCOS features
• Previous pelvic infection

Male clues

• Erectile problems
• Ejaculation problems
• Low libido
• Testicular swelling
• Varicocele history

Treatment of Infertility is cause-specific. The aim is to restore ovulation, improve sperm quality, correct anatomical problems, and help the egg and sperm meet. Management usually progresses from lifestyle measures → medicines → procedures → assisted reproduction (IUI/IVF/ICSI).

Stepwise line of treatment of infertility

Step 1

Lifestyle optimisation

Weight control, stop smoking/alcohol, exercise, sleep, folic acid.

Step 2

Ovulation induction medicines

Letrozole, clomiphene, gonadotropins, metformin (selected cases).

Step 3

Treat specific causes

Thyroid, prolactin, infections, varicocele, tubal disease, endometriosis.

Step 4

Intrauterine insemination (IUI)

Prepared sperm placed inside uterus near ovulation.

Step 5

IVF / ICSI

Egg retrieval and fertilisation in the laboratory.

1. Lifestyle treatment (first step for all couples)

2. Ovulation induction medicines (female infertility)

Used when the woman is not ovulating regularly.

A. Letrozole (first-line in PCOS)

Class: Aromatase inhibitor.

Mechanism

1 Inhibits aromatase enzyme.

2 ↓ Conversion of androgens → estrogens.

3 ↓ Estrogen feedback to hypothalamus/pituitary.

4 ↑ FSH secretion.

5 Stimulates growth of ovarian follicles and induces ovulation.

Common use

• Polycystic Ovary Syndrome-related infertility.

Advantages

• Higher ovulation and live birth rates than clomiphene in many PCOS patients.

B. Clomiphene citrate

Class: Selective estrogen receptor modulator (SERM).

Mechanism

1 Blocks estrogen receptors in hypothalamus.

2 Brain senses low estrogen.

3 ↑ GnRH release.

4 ↑ FSH and LH secretion.

5 Follicular development and ovulation occur.

Limitation

• Can thin the endometrium and alter cervical mucus with prolonged use.

C. Gonadotropin injections (FSH / hMG)

Examples: Recombinant FSH, hMG.

Mechanism

• Provide exogenous FSH directly to the ovary, stimulating follicle growth.

Use

• Failure of oral ovulation induction.
• Controlled ovarian stimulation for IUI or IVF.

Risk

• Multiple pregnancy and ovarian hyperstimulation syndrome (OHSS).

D. hCG trigger injection

Mechanism

• Mimics the natural LH surge, causing final maturation and release of the egg.

Use

• Given when the follicle reaches adequate size before timed intercourse, IUI, or IVF.

E. Metformin (in selected PCOS patients)

Mechanism

• Improves insulin sensitivity → lowers insulin levels → reduces ovarian androgen production → improves ovulation.

Best suited for

• Overweight or insulin-resistant women with PCOS.

3. Hormonal correction

4. Luteal phase support

Progesterone

Forms: Vaginal capsules, tablets, injections.

Mechanism

• Converts endometrium to a secretory phase suitable for implantation.
• Supports early pregnancy until placental progesterone production is adequate.

Common after

• Ovulation induction, IUI, and IVF.

5. Treatment of tubal and pelvic disease

A. Infection treatment

• Appropriate antibiotics for pelvic infection.

B. Tubal surgery

• Adhesiolysis, tubal repair, or hydrosalpinx surgery.

Mechanism

• Restores tubal patency and egg transport.

C. Endometriosis surgery

• Laparoscopic removal of endometriotic lesions and adhesions.

Mechanism

• Reduces inflammation and improves pelvic anatomy.

6. Male infertility treatment

A. Lifestyle optimisation

• Stop smoking, alcohol, anabolic steroids; weight reduction.

B. Treat varicocele

• Varicocelectomy may improve sperm parameters.

C. Hormonal therapy (selected men)

Used mainly in hypogonadotropic hypogonadism.

7. Intrauterine insemination (IUI)

Procedure

Prepared motile sperm are placed directly into the uterus around ovulation.

Mechanism

• Increases the number of motile sperm reaching the fallopian tube.
• Bypasses cervical factors.

Indications

• Mild male factor infertility
• Unexplained infertility
• Cervical factor infertility
• Ovulatory infertility after stimulation

8. In vitro fertilization (IVF)

Steps

Ovarian stimulation → egg retrieval → fertilization in laboratory → embryo transfer.

Mechanism

• Bypasses fallopian tubes and allows fertilization outside the body.

Indications

• Bilateral tubal blockage
• Severe endometriosis
• Long-standing unexplained infertility
• Failure of IUI
• Advanced maternal age

9. Intracytoplasmic sperm injection (ICSI)

Mechanism

A single sperm is injected directly into the egg cytoplasm.

Main indication

• Severe male factor infertility (very low count, motility, or surgically retrieved sperm).

Cause-wise treatment summary

Precautions and lifestyle changes for infertility

1. Maintain a healthy body weight

For women

• Overweight/obesity: can cause irregular ovulation, especially in Polycystic Ovary Syndrome.
• Underweight: may stop ovulation and periods.

For men

• Obesity can lower testosterone and reduce sperm count and motility.

Target: BMI roughly 18.5–24.9 kg/m².

Even a 5–10% weight loss in overweight women with PCOS may restore ovulation.

2. Eat a fertility-friendly diet

Eat more

• Green leafy vegetables
• Fruits (orange, guava, berries, apple)
• Whole grains (oats, brown rice, millets, whole wheat)
• Pulses, beans, dals
• Milk, curd, paneer in moderation
• Eggs, fish, lean meat if non-vegetarian
• Nuts and seeds (almonds, walnuts, flaxseed, pumpkin seeds)

Important nutrients

Limit

• Deep-fried foods
• Bakery items, pastries, excess sugar
• Sugary drinks
• Processed meats and fast food

3. Stop tobacco completely

Smoking is one of the strongest avoidable causes of infertility.

Women

• Earlier decline in ovarian reserve
• Reduced IVF success
• Increased miscarriage risk

Men

• Lower sperm count
• Poor motility
• Increased sperm DNA damage

Avoid cigarettes, bidis, hookah, vaping, and smokeless tobacco.

4. Avoid or minimise alcohol

• Best approach while trying to conceive: avoid alcohol.
• Alcohol can impair ovulation and sperm quality.

5. Exercise regularly

Aim for 150 minutes/week of moderate exercise such as brisk walking, cycling, swimming, or yoga.

Avoid

• Extreme endurance exercise
• Very heavy gym training every day
• Rapid weight-loss programmes

Excessive exercise can suppress ovulation.

6. Sleep adequately

Aim for 7–8 hours of sleep nightly.

Poor sleep may disturb reproductive hormones and increase stress.

• Keep a regular sleep schedule.
• Reduce late-night screen exposure.

7. Manage stress

Stress alone usually does not cause infertility, but it can worsen hormonal imbalance and reduce treatment adherence.

Helpful methods:

• Meditation
• Deep breathing
• Yoga
• Prayer/spiritual practices
• Counselling or support groups
• Hobbies and social support

Specific precautions for men

Keep the testes cool

Avoid prolonged heat exposure:

• Hot tubs, sauna, steam baths
• Tight underwear for long hours
• Laptop on lap
• Long-distance driving without breaks

Prefer loose cotton underwear.

Avoid anabolic steroids

Gym steroids can shut down sperm production and cause severe infertility.

Review medicines

Discuss with a doctor if taking:

• Testosterone injections or gels
• Finasteride
• Certain psychiatric medicines
• Chemotherapy drugs
• Some anti-epileptic drugs

Do not stop prescribed medicines without medical advice.

Specific precautions for women

Track ovulation

• Regular cycles: fertile window is usually about 5 days before ovulation and the day of ovulation.
• Intercourse every 1–2 days during the fertile window is usually sufficient.

Avoid excessive use of home ovulation kits that creates anxiety.

Take folic acid before conception

• 400–800 mcg daily, starting at least 1 month before pregnancy.

Control medical conditions before conception

Ensure good control of:

• Diabetes
• Thyroid disease
• High blood pressure
• Epilepsy
• Asthma

Pre-pregnancy control improves fertility and pregnancy outcomes.

Sexual lifestyle advice

Environmental precautions

Reduce exposure to:

• Pesticides
• Industrial solvents
• Paint fumes
• Heavy metals (lead, mercury)
• Excessive radiation

Use protective equipment if occupational exposure is unavoidable.

Before fertility treatment (IUI/IVF)

• Stop smoking and alcohol ideally 3 months before treatment.
• Maintain healthy weight.
• Take prescribed folic acid and other supplements.
• Attend all ultrasound and blood-test appointments.
• Avoid starting new herbal or fertility products without informing the doctor.

Warning signs needing medical review

Seek medical advice if:

• No pregnancy after 12 months (or 6 months if woman ≥35 years)
• Irregular or absent periods
• Very painful periods
• Previous pelvic infection or tuberculosis
• Testicular swelling, pain, or varicocele
• Erectile or ejaculation problems
• Recurrent miscarriage

A simple daily fertility routine

Morning

Healthy breakfast + folic acid + 20–30 min walk

Daytime

Balanced meals, adequate water, avoid smoking/alcohol

Evening

Light exercise or yoga, stress-reduction practice

Night

Early dinner, no tobacco/alcohol, 7–8 h sleep

The 10 habits that help fertility the most

1.      Healthy weight

2.      Stop tobacco

3.      Avoid alcohol

4.      Exercise regularly

5.      Sleep 7–8 h

6. Manage stress

                        7. Balanced diet

                        8. Folic acid daily

                        9. Avoid testicular heat

                      10. Regular intercourse

Common supplements used in infertility

1. Folic acid / L-methylfolate

Common brands in India

Typical dose: 400–800 mcg daily before conception.

2. Myo-inositol + D-chiro-inositol (especially in PCOS)

Purpose: Improves insulin sensitivity and ovulation in Polycystic Ovary Syndrome.

3. Coenzyme Q10 (CoQ10)

Common dose: 100–300 mg/day.

Useful in women with reduced ovarian reserve and men with poor sperm motility.

4. L-carnitine / Acetyl-L-carnitine (male infertility)

Common dose: L-carnitine 1–2 g/day.

5. L-arginine

Common dose: 1–3 g/day.

Often used for endometrial support and male fertility formulations.

6. Omega-3 fatty acids

7. Zinc + Selenium combinations (male fertility)

Contain zinc, selenium, folate, antioxidants, and amino acids.

8. Vitamin D3

Use according to vitamin D level and doctor’s advice.

9. Vitamin E + Vitamin C antioxidant combinations

10. Astaxanthin / Lycopene combinations

Commonly included in male fertility antioxidant products.

What is commonly prescribed in practice?

Female infertility with PCO 

Typical supportive combination

Ovacare Myo                             1 sachet/tablet twice daily

Folvite                                           400–800 mcg daily

Uprise-D3                                    If vitamin D deficient

Steps

Ovarian stimulation → egg retrieval → fertilization in laboratory → embryo transfer.

Mechanism

• Bypasses fallopian tubes and allows fertilization outside the body.

Indications

• Bilateral tubal blockage
• Severe endometriosis
• Long-standing unexplained infertility
• Failure of IUI
• Advanced maternal age

9. Intracytoplasmic sperm injection (ICSI)

Mechanism

A single sperm is injected directly into the egg cytoplasm.

Main indication

• Severe male factor infertility (very low count, motility, or surgically retrieved sperm).

Cause-wise treatment summary

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