Questions, answered.

Infertility is defined as the inability to conceive after 12 months of regular and unprotected intercourse. A full infertility workup is therefore recommended when a couple has met this threshold.

In women older than 35 years of age, and in certain cases with a positive history, a full evaluation is warranted earlier, after 6 months of intercourse.

Infertility is considered primary when the couple has never conceived, and secondary when the couple has had at least one successful conception in the past.

Infertility is a major health issue worldwide, affecting 10 to 15% of couples (1 in 6 to 8 couples). The causes are usually grouped into four categories:

Several factors impact a woman’s fertility:

1. Age and ovarian reserve. A woman’s fertility progressively declines with age. There is a significant age-related decrease in the quantity and quality of oocytes, referred to as the ovarian reserve. Peak fertility years extend from the early twenties till the early thirties, and continuously decline afterwards.
2. Ovulation disorders. Abnormal or absent ovulation is a leading cause of female infertility. Dysfunctions of regulatory hormones or the ovary can lead to ovulation disorders, such as Polycystic Ovarian Syndrome, hypothalamic dysfunction, hormonal imbalances (abnormal thyroid function, high prolactin), or premature ovarian insufficiency. Ovulation can also be impacted by external factors such as weight, exercise, or medication.
3. Uterine and cervical factor. A normal uterus and endometrial lining are essential for adequate implantation and normal progress of pregnancy. Uterine fibroids and endometrial polyps can cause infertility and recurrent pregnancy loss, depending on their location and size. Other causes include uterine adhesions, congenital uterine malformations, adenomyosis, and cervical stenosis.
4. Tubal factor. Any damage to the Fallopian tubes can cause infertility, by blocking the sperm from reaching the oocyte for fertilization, or the embryo from reaching the uterine cavity for implantation. The tubes can be blocked due to abdomino-pelvic surgery, pelvic inflammatory disease, or endometriosis.
5. Systemic illnesses. Severe systemic diseases (active autoimmune disorders, hormonal deficiencies, severe renal disease, uncontrolled diabetes) and malignant disorders, as well as many chronic treatments (chemotherapy, radiotherapy, immunomodulators), can be associated with infertility and recurrent pregnancy loss.
6. Environmental and lifestyle factors. Smoking, heavy alcohol consumption, obesity, a sedentary lifestyle, and exposure to certain chemicals and pollutants are all known to reduce female fertility. Most of these factors are at least partially reversible.

Several factors may impact a man’s sperm production and fertility:

1. Testicular conditions. Sperm production occurs exclusively in the testes, and could therefore be significantly impacted by any testicular condition. Causes can be congenital (chromosomal abnormalities, cryptorchidism) or acquired (varicocele, testicular tumors, testicular infection, a history of chemotherapy or radiotherapy, a history of testicular trauma or injury).
2. Post-testicular conditions. After production, sperm cells move to the epididymis where they mature and are stored, before going through the vas deferens and the urethra during ejaculation. Anomalies in these ducts can be congenital (cystic fibrosis, congenital absence of vas deferens) or acquired (infection, trauma or surgery, erectile or ejaculatory dysfunction).
3. Pre-testicular conditions. Sperm production is under the control of the hypothalamic-pituitary axis via the gonadotropins (FSH and LH), as well as testosterone. Disruptions of the axis can lead to abnormal sperm production, as seen with pituitary insufficiency, exogenous hormone intake (anabolic steroids, corticosteroids), hormone imbalances, and some congenital conditions such as Kallmann syndrome.
4. Age. Even though the impact of age on a man’s fertility is less pronounced than in women, recent studies have shown that sperm production decreases with age. The impact is more pronounced after the age of 45 to 50, and is accompanied by an increase in the risk of miscarriage and adverse outcomes in the offspring.
5. Environmental and lifestyle factors. Obesity, a sedentary lifestyle, heavy alcohol consumption, smoking, exposure to chemicals and pollutants (pesticides, heavy metals), electromagnetic waves, and X-rays can all significantly alter sperm production. The impact is related to the amount and duration of exposure, and is often reversible.

Unexplained infertility accounts for approximately 15% of all infertility cases, and refers to the absence of an identifiable cause for the couple’s failure to conceive, despite a full workup.

Many cases of unexplained infertility can be caused by the presence of multiple factors that do not significantly reduce fertility on their own, but can have an impact when combined. Unexplained infertility requires active management in most cases, especially when the duration of infertility is long.

The classic threshold is 12 months of regular, unprotected intercourse without conception. After 35, that drops to 6 months. We also recommend an earlier visit when there is a known history that could affect fertility: irregular cycles, endometriosis, previous pelvic surgery, varicocele, testicular surgery, or any treatment that may impact sperm or oocyte production.

Even before trying, a couple can come in for an evaluation if they want to understand their reproductive health, or are considering fertility preservation.

The first visit is a conversation. We sit down with both partners when possible, go through the personal and family medical history, and review any previous workup or treatment.

At the end of that visit, we agree on the next steps together. That usually means a structured workup (hormonal markers, imaging, semen analysis) within the same cycle, so that the second visit can be a full discussion of results and options.