Childlessness - infertility

Causes of infertility

There are many possible reasons why couples can experience difficulty conceiving. One or both partners may have a problem of some kind, and it may not always be possible to identify the underlying cause. This is known as unexplained infertility. 

The main reasons why some women are unable to conceive are: 

• Ovaries not releasing eggs regularly. This is called irregular ovulation (ovulation disorders) and is the main problem encountered by a third of the women. One of the most common reasons for this is a condition called polycystic ovary syndrome (PCOS). PCOS is caused by a hormonal imbalance. 
• Around 15 in every 100 women have damaged or blocked fallopian tubes. The fallopian tubes are the tubes that connect your ovaries to your uterus. If these tubes are blocked, the woman’s eggs and the man’s sperm will not be able to reach each other. Untreated chlamydia or other fallopian tube infections can cause blocked fallopian tubes. 
• Around five in every 100 women who do not become pregnant have a condition called endometriosis. Cells from the lining of the uterus, the endometrium, start to grow outside the uterus, sometimes around the ovaries and fallopian tubes. 
• The ability to become pregnant (fertility) declines from the age of 35 (and at an even faster rate from the age of 40). 
• Some women also experience early menopause. This is when the ovaries stop releasing eggs. This usually happens between the ages of 45 and 55. However, it can happen earlier in some women. 
• A small number of women do not produce enough of the two hormones that trigger ovulation. These hormones are called luteinizing hormone (LH) and follicle-stimulating hormone (FSH). 
• Benign growths in the uterine wall called uterine nodules or fibroids can prevent a fertilised egg from growing in the uterus. 

Most men with fertility problems have one or more of the following problems: 

• Too few sperm, i.e. a low sperm count 

• Abnormally shaped sperm that cannot move normally or fertilise eggs 

• Sperm that are poor swimmers 

A normal sperm sample should contain between 20 and 300 million sperm per millilitre. At least half of these should be motile and swim in a forward direction. If you have fewer sperm than this, your sperm count is low. This does not mean you are completely infertile, but conceiving may take longer. Some men have very few sperm or even no sperm at all. A low sperm count can be caused by an imbalance of hormones, previous injury to the testes, an infection in the testes or the man’s genes. 

Some men produce sperm, but have erection problems or difficulty ejaculating. The latter can be caused by a blockage in the tubes between the testicles and the penis. The sperm can also be directed “backwards” into the bladder, rather than out through the urethra. This can be caused by a nerve injury. Nerve damage can be caused by diabetes or previous surgical procedures.

Investigating infertility

If you have been trying to conceive a child for over a year, you will probably be referred to a specialist for further investigation. Women over the age of 35 may be referred earlier. Women will be assessed by a gynaecologist, while men will be referred for analysis of their semen at a hospital. When you are referred for further investigation, the doctor will often ask you a number of personal questions, such as how long you have been trying to conceive and how often you have sex. Women will be asked about any previous pregnancies, sexually transmitted diseases, previous infections, whether she has undergone any surgical procedures, what contraception she has used and when she stopped using it, any medications she is taking, and her menstrual cycle. Men will be asked if they have ever had mumps. You will also be asked about your general health and lifestyle. 

Tests for fertility problems

The doctors will arrange for you both to have the necessary tests. 

For women, this will involve a blood test around day 21 of their menstrual cycle. This will check whether you are ovulating normally. The level of hormones released when you ovulate will be measured. Hormone levels may also be checked earlier in your menstrual cycle. 

For men, this will involve providing a semen sample. The sample will be analysed to see whether your sperm count is normal and whether your sperm are of normal shape and appearance when viewed under a microscope. 

In the case of abnormal ovulation or sperm quality, your doctor may give you treatment advice. If the tests indicate ovulation and semen quality are both normal, the woman will probably be asked to have a number of other tests in order to look for other possible causes. 

Additional investigations 

Doctors may perform further examinations to find out more about your infertility. 

Hysterosalpingography 

A hysterosalpingography is an X-ray procedure which shows the inside of a woman’s uterus and fallopian tubes. The radiologist may look for blockages or tumours. This examination can be painful, and your doctor may advise you to take pain medication in advance. During the test, the doctor will inject a contrast agent into your uterus through your cervix. The agent will be visible on X-rays, which enables the doctor to see whether it has passed through your cervix and along your fallopian tubes. If your fallopian tubes are blocked, the doctor will be able to see that the agent does not pass through them. 

Vaginal ultrasound examination 

The doctor may also insert an ultrasound probe in your vagina to obtain images of your uterus and fallopian tubes. This is called a vaginal ultrasound. Ultrasound can sometimes show how eggs grow in the ovaries. 

Keyhole surgery (laparoscopy) 

The doctor may want to look at your ovaries, fallopian tubes and uterus. This can be done using keyhole surgery (laparoscopy) through the abdominal wall. You will probably need anesthesia. The doctor will insert a tube with a camera on the end through a small incision near your belly button. A laparoscopy can reveal endometriosis, blocked or damaged fallopian tubes, ovarian cysts and uterine nodules. The doctor may take tissue samples, remove any tumours and repair certain injuries. 

A laparoscopy carries a small risk of bleeding or injury to other parts of the body. It may take a little while to recover from the procedure. If the results of other tests are normal, you must consult your doctor and decide whether you should have this investigation. You may be able to receive treatment without having this investigation first.

Treatment for infertility

There are various treatments available for assisted reproduction. Below, you can read more about these methods and find explanations of the terms and phrases used in the various treatments. 

If the tests show a clear cause of your fertility problems, your doctor will be able to tell you which treatment will give you the best chance of conceiving. However, it is not always possible to identify a cause, and the treatment can be sometimes be complicated. 

You will need to consider possible side effects, the emotional strain and in certain cases the cost of treatment too. 

Medications 

If a woman has ovulation problems or unexplained infertility, clomiphene will probably be recommended first. 

Clomifene 

Clomifene stimulates ovulation. After two, three or four cycles of treatment with clomiphene, around 70 in every 100 women with ovulation problems ovulate, and around 35 in every 100 become pregnant. Three times more women become pregnant with clomiphene than without treatment. 

Clomifene can cause certain side effects, but these are rarely serious. You may gain weight and experience swelling in your body. If you become pregnant while taking clomiphene, there is a slightly higher chance of having multiples, i.e. twins or triplets. On rare occasions, more than three eggs can be fertilised. This happens because clomiphene can cause the ovaries to release more than one egg at a time. However, the risk does not increase by very much. One in ten women who become pregnant when using clomiphene have more than one child. 

If you have polycystic ovary syndrome (PCOS) and clomiphene does not help, you may be advised to try a drug called metformin. 

If these medications do not help, your doctor may consider treatment with aromatase inhibitors or hormone injections. 

Hormone injections

Hormone injections contain follicle-stimulating hormone (FSH) and/or luteinizing hormone (LH). They help you to ovulate, i.e. to ripen your eggs ready for ovulation. If you have polycystic ovary syndrome (PCOS) and are undergoing treatment with hormone injections, you will have a 10-30 percent chance of getting pregnant during each menstrual cycle. Hormone injections are also used if your body does not produce the necessary hormones itself (hypogonadotropic hypogonadism). Hormone injections are administered daily for up to twelve days from the start of menstruation. Using ultrasound, it is possible to check whether your eggs are sufficiently ripe for ovulation. 

One side effect of hormone injections is known as ovarian hyperstimulation syndrome (OHSS). This causes the ovaries to swell up. Mild symptoms include swelling of the legs or arms, weight gain and a bloated feeling in the abdomen. Around two in every 100 women experience more serious side effects, such as nausea or vomiting, shortness of breath and kidney or liver problems. Discontinue hormone therapy and seek medical advice immediately. 

As with clomiphene, hormone injections increase the likelihood of multiples. 

Hormone injections are often combined with a treatment where the sperm are placed directly in the uterus. This is known as insemination and can give you a better chance of conceiving than sexual intercourse. Insemination can help when sperm quality is poor, i.e. in the case of a low sperm count or sperm that are poor swimmers. 

Surgical procedures

If endometriosis or fibroids in the uterus are suspected as being the cause of infertility, surgery may help. 

On rare occasions, surgeons may try to repair blocked fallopian tubes, but this procedure can be complicated. 

In the case of ovulation problems, the surgeon may make small holes in the ovary (laparoscopic drilling) to facilitate egg release. 

As with any type of surgery, there is a small risk of complications, such as infection following surgery or reactions to the anesthetic. 

Involuntary childlessness and assisted reproduction

If you and your partner require assisted reproductive treatment, Helfo can cover fertility drugs exceeding NOK 17,730.

Illustration: Morten Rakke / Helfo

Assisted conception and other methods

Insemination (IUI) 

During insemination, pre-prepared sperm is introduced into the woman using a catheter. The timing of the insemination is coordinated with the woman’s ovulation. This method assumes an adequate sperm count, ovulation and at least one open fallopian tube. 

In vitro fertilisation (IVF) 

In vitro fertilisation (IVF) is the most common form of assisted reproduction.  

In the case of IVF, fertilisation occurs outside the woman’s body, rather than in the fallopian tubes, where it normally happens. 

The treatment involves extracting eggs from the woman and fertilising them in a laboratory. The doctor then inserts the fertilised egg, now called an embryo, into the woman's uterus. 

IVF can be used in the following cases: 

• unknown cause of infertility 

• ovulation difficulties 

• blocked fallopian tubes 

• reduced sperm quality 

Before treatment, the woman must be given hormone injections to control her ovulation. Risks and complications associated with in vitro fertilisation are rare. There may be a risk of bleeding, allergic reactions, infections and other side effects of the medications that are used. In addition, some people find the treatment very stressful. Two in every 100 people experience severe “hyperstimulation syndrome”, which is caused by the hormone treatment. This can be serious and necessitate admission to hospital. It is important that women who are at risk of developing hyperstimulation are well-informed about the condition. It is therefore important that you consider the consequences, both positive and negative, before agreeing to have the treatment. You can discuss this with both your doctor and your partner, if you have one. 

One in three women under 35 years of age will have a child on their first attempt. The chances of becoming pregnant diminish somewhat above this age. 

The risk of miscarriage also increases with age. Up to two in 10 women suffer a miscarriage even though the treatment at the clinic was successful. However, there are a number of factors that come into play. Ask your doctor what your chances of conceiving are. 

To avoid pregnancies with twins or triplets, it is common to insert a single fertilised egg. If there are several high-quality embryos, these will be frozen for possible future use. 

Children born following IVF are at a slightly higher risk of being born prematurely and having a low birth weight. This is probably due to the increased number of twin births and the fact that more older women have IVF, rather than the IVF procedure itself. There is no evidence of any increase in the risk of birth defects with IVF. 

Intra-cytoplasmic sperm injection 

Intra-cytoplasmic sperm injection (ICSI) may be relevant in cases where the man’s sperm count is very low, i.e. where there are only a few sperm or perhaps none at all. ICSI is a variant of IVF where a healthy male sperm is injected directly into the female egg in order to fertilise it. The fertilised egg is then put back into the woman’s uterus, as in the case of IVF. 

ICSI has been the subject of research for the past 22 years. Children conceived via ICSI develop normally compared with other children, but they may be at a slightly higher risk of having certain genetic defects. 

Sperm and egg donation 

Single women and couples can also be treated using eggs or sperm from someone other than their partner. Single women are not entitled to assisted reproduction with egg donation. Egg donation was permitted in Norway from 1 January 2021. 

You will find information for egg and sperm donors here. 

Egg extraction 

Eggs are extracted from the woman for fertilisation in a laboratory using IVF. 

Reinserting fertilised eggs (embryo transfer) 

Fertilised eggs can be introduced into the woman via a catheter. Before the egg is reinserted, the woman may be treated with drugs, or her own menstrual cycle may be used.  

Use of eggs and sperm in assisted reproduction 

Eggs, sperm and fertilised eggs can be frozen, stored, transported and thawed before they are used in assisted reproduction. 

Self-help for infertility

There are also some things you can do yourself to improve your chances of having children. This also applies if you decide to have treatment:

• Maintain a healthy weight. Being over- or underweight can reduce your chances of becoming pregnant. If you are overweight, you should try to lose weight before your GP refers you for an infertility assessment. 
• Stop smoking. Men and women who smoke are more likely to have reduced fertility, and women are at greater risk of suffering a miscarriage. 
• Have sex every two or three days, especially around the time of ovulation.

Prognosis in connection with infertility

The chances of becoming pregnant depend on many different factors. The age of the woman is the single most important factor, because egg quality declines after the age of 35. Results also vary with the type of treatment and the cause of the infertility. Some clinics also produce better results than others. 

Some couples with fertility problems have children after a period without medical intervention. One to two involuntary childless women in every hundred become pregnant each month without treatment.