What Causes Infertility? Common Causes Explained

We need a good, plush endometrial lining, and if it isn't good we have medicines that can improve it. For example, in a recent case of severe intrauterine adhesions from a missed abortion managed elsewhere, the endometrial thickness was under 1mm in places and completely scarred. We did adhesiolysis and then gave a combination of estrogen and progesterone — estrogen helps regenerate the endometrium. It takes about 3 months for regeneration, though outcomes depend on how bad the scarring is; in some patients with very severe scarring we may not be able to regenerate a good lining at all.

We generally say at least 3 to 4 months of contraception should be used, and conception should not happen within that window.

There are now government of India guidelines on this. Strictly by those guidelines it is 50 for the woman and 55 for the man, though this used to be more liberal — we used to see people at 60–65 also getting IVF done, before the ethical question of who will care for the children led to the cutoff being tightened.

After adhesiolysis we give a combination of estrogen throughout the cycle and progesterone added in the last 14 days, and it takes about 3 months for regeneration, confirmed with transvaginal sonography for endometrial thickness before and after. Many patients start to show improvement even after about a month and a half, where the scarring and adhesions are not so severe that they have permanently damaged the endometrium.

A lot of times when an HSG is done without sedation, the patient tenses up so much that there is a tubal spasm, which can appear as a bilateral proximal tubal blockage. One good approach is to give the patient an anti-spasmodic before the procedure, or do it with a little sedation, which removes many of these false positives. But if it still appears to be a genuine proximal blockage in both tubes, it's better to go directly for a diagnostic hysterolaparoscopy with chromopertubation, since that lets you directly visualise the tubes — and most patients also find repeating an HSG very painful.

Uterine problems such as fibroids, polyps within the cavity and intrauterine adhesions can all interfere with fertility, and fallopian tube problems are also common, being one of the most frequent reasons patients require IVF.

Since ovulation is the first essential step in pregnancy, disorders such as thyroid disease, polycystic ovarian syndrome and hyperprolactinaemia can all disrupt it and lead to infertility.

Premature ovarian insufficiency is a condition where periods stop before age 40, and it is becoming more common globally.

Yes. Pelvic adhesions sometimes resulting from prior cancer treatment involving the uterus or ovaries are a recognised cause of infertility that should be considered during a pre-IVF workup.