Infertility (Mate matapā)

In men

Fertility problems can be due to low or absent sperm numbers, or abnormal sperm movement or shape. A cause of abnormal sperm is not always found.

The testicles (testes) produce and store sperm. If they are damaged, it can affect the quality of the sperm. Damage to the testes can occur with:

• an infection of the testes
• testicular cancer
• surgery or injury to the testes
• undescended testes as a baby
• sterilisation/vasectomy – this can be reversed but it doesn't always work
• ejaculation problems during sex
• medications, eg, anabolic steroids or chemotherapy
• medical conditions – when you are unwell (eg, with flu or COVID) it can temporarily impair sperm quality
• illegal drugs, eg, marijuana and cocaine
• cigarette smoking as it reduces sperm quality.
• anatomical problems, eg, absence of vas (tube transporting sperm) or varicocele (enlarged veins in the scrotum).

In women

Fertility problems can be caused by problems with ovulation (the monthly release of an egg from the ovaries) and by damage to the fallopian tubes. This includes the following:

• Pelvic infections, eg, chlamydia can damage the fallopian tubes.
• Polycystic ovarian disease or other ovulatory problems may stop you ovulating or mean that you ovulate less frequently.
• Endometriosis can damage the ovaries or fallopian tubes.
• Premature ovarian failure – this is when the ovaries stop working before the age of 40 years. However, fertility reduces in women after the age of 35.
• Fibroids (non-cancerous growths of the wall of the uterus) can sometimes contribute to infertility.
• Medications can impact on fertility. For example, some chemotherapy can damage the ovaries and antipsychotic medications can stop you ovulating.

There are some changes you can make to your lifestyle to increase your chances of getting pregnant. These include:

• Regular sex: You should have sex every 2–3 days leading up to ovulation.
• Don’t smoke: Smoking reduces fertility in both men and women.
• Avoid illicit drugs such as marijuana: these reduce fertility in both men and women.
• Be a healthy weight: being overweight and being underweight can reduce your fertility – aim for a BMI between 18.5 and 25.
• Cut down on alcohol: Heavy drinking is linked to reduced fertility.
• Cut back on caffeine: High caffeine intake may reduce fertility.

You should see a doctor if you haven’t got pregnant after 12 months. You should see a doctor sooner if:

• You are aged over 35 years (fertility reduces as you get older).
• You have a condition that may impact on fertility such as polycystic ovary syndrome (PCOS), endometriosis or previous surgery to your testes.
• You don’t get periods or get very infrequent periods.

For men

Semen analysis can be done to check for problems with sperm, eg, a low sperm count or sperm not moving properly.

For women

Hormone levels can be checked, these will be timed by your menstrual cycle:

• FSH and oestradiol: These check your ovarian reserve (how many eggs are left in your ovaries) and are done on day 2–4 of your menstrual cycle.
• Progesterone: This checks that you are ovulating (releasing an egg from your ovary) and is checked 7 days before your period is due.
• Prolactin level
• Anti-müllerian hormone (AMH) test: This can help predict how you will respond to an IVF (in vitro fertilisation) cycle. It may help identify women who will go through an early menopause. It doesn't predict ovarian reserve in women who have polycystic ovary syndrome (PCOS). 

Antenatal blood tests are blood tests done to check that you are immune to rubella and that you don't have hepatitis B, syphilis or HIV. These are checked for all pregnant people in Aotearoa New Zealand, and should be checked in case vaccination or treatment is needed before you get pregnant. 

Tests to check your tubes are working. These include:

• Hysterosalpingo-Contrast Sonography (HyCoSy): An ultrasound procedure used to assess the patency of the fallopian tubes (whether they are open or blocked) and to detect abnormalities of the uterus. 
• Laparoscopy: This is keyhole surgery performed by a gynaecologist. It can be done to look for endometriosis or to test that your fallopian tubes are working.

A range of treatments for fertility problems is available, including:

• medication to improve ovulation, eg, clomifene or letrozole
• surgery to investigate and treat anatomic issues such as endometriosis or fibroids
• insemination with a partner's or donor sperm (IUI)
• In vitro fertilisation (IVF)
• IVF with intra cytoplasmic sperm injection (ICSI).

Success rates vary depending on the treatment and the cause of infertility.

If you are considering fertility treatment, here are some questions to ask during your discussions:

• What is my/our diagnosis?
• What are my/our options?
• What are the chances of success with each option?
• How much is each option likely to cost?
• Are there side effects?
• Is a counselling session included?
• How will I/we find out the results?

Infertility is not merely a physical condition, it is an emotional and social condition as well. It carries with it intense feelings that need careful support from the doctors, nurses, counsellors and technicians involved.

Stress: Treatments can take many months to complete and involve tests for both males and females. This period of waiting, investigations and treatments can prove stressful.

Grief: Common feelings such as anger and frustration, loss of control, isolation from friends and family, depression and grief may seem overwhelming if you are being denied a child you earnestly wish to conceive and parent.

Crisis point: At some point during infertility treatment, or investigation, you may experience this as a state of crisis. This crisis, in turn, may lead to further isolation and despair. This may place strain on relationships as well. You may feel alone and not have anyone to talk to who understands the experience of infertility.

Infertility is a crisis of the deepest kind. It is experienced as an on-going grief, a grief in which many couples feel alone and isolated. It can threaten every aspect of your life - your sense of self, dreams for the future and your relationship with others. Few crises are as challenging and overwhelming. 

In talking about this grief reaction and the crisis that people go through, Sue Saunders, the author of ‘Infertility: A guide for New Zealanders’, describes infertility as a series of losses:

“The loss of dreams and hopes; the loss of power and control of your life; the loss of autonomy as medical professionals become more involved in your life; the loss of body image and competent functioning; the loss of perceived status in the eyes of others; the loss of security and stability within life and the important loss of self-esteem. All these losses need to be acknowledged and worked through to resolve the grief that accompanies infertility." 

Several couples are quoted in the book, including a man who wrote in his journal:

“For 12 months I have been on an involuntary emotional rollercoaster. My life was picked up and smashed on the ground, what I had expected and taken for granted was thrown away. Forever since, I have been trying to put back together what remains....It has taken me a long time going through my emotions to realise what I can do....Just as the branches on a tree are strengthened by a strong wind, so should life's hard knocks enrich and strengthen our lives. Don't let infertility break you.”

The thing he found helpful was to control the stress by yelling, crying, running and gardening. The other things he found useful were getting counselling and meeting others in the same situation.

Some of the best ways to deal with infertility are to be informed and to talk about it. This is not always easy or comfortable. If you are dealing with infertility, you might find it helpful to: 

• talk to friends and whānau who are supportive
• see a counsellor to talk through your feelings and options
• talk to someone else who has been through what you are going through and who understands. 

• Stress causes infertility: There is little evidence for that but infertility can certainly cause stress.
• Relaxing or having a holiday will solve my infertility problems: It is very unlikely as up to 80% of couples have a medical cause for their infertility.
• If I adopt I will be more likely to then conceive a baby: There is no evidence that adopting or not adopting changes to likely possibility of getting pregnant.
• Treatment is always successful: Many couple will take more than one treatment cycle to conceive and unfortunately some never will.