Infertility afflicts about one couple in 6 or 7 but nevertheless lies somewhat outside the scope of this book. Because so many abortions are being done fewer babies are available for adoption so the topic is becoming one of increasing importance. With the constant coverage of ‘test-tube’ methods in the popular press infertility, once a taboo area, is now widely discussed.

For conception to occur, a sperm capable of fertilising an ovum which is capable of being fertilised have to meet and fuse, and for a baby to grow normally the fertilised ovum has to develop efficiently and the woman’s body has to provide for it and protect it efficiently.

For all this to happen a man has to be capable of producing sufficient sperms of adequate quality and has to deliver them to the top of the vagina. Male genital malformations causing infertility are increasing for unknown reasons and sperm counts have been falling consistently since 1960, at least in the US. Increasing stress may be a reason since sperm counts in students, for example, fall when their examinations are due. Another related reason may be that

intercourse rates are falling, according to some researchers. Some men produce healthy sperms in the testis but by the time they are ejaculated large numbers have lost their tails and look

moth-eaten under the microscope. The presumption is that the sperms are being damaged in the epididymis. If ejaculation rates are raised sperms spend less time between testis and penis and so might be less damaged. Getting such men to ejaculate twice a day does in fact improve sperm quality.

One way in which these sperms might have been damaged is by the man’s body making antibodies to his own sperms. Normally this does not happen but it can do if sperms reach the blood stream because of an injury to or obstruction of the tubes through which they pass. One way round the problem is to obtain an egg (by stimulating the ovaries hormonally and then retrieving the eggs laparoscopically) from the partner, wash the sperms free of antibody and bring about fertilisation in a test-tube. A woman’s body may also make antibodies to her partner’s sperms but this is not common because sperms usually have the ability to suppress such a response. The same test-tube technique can be used to overcome this problem but another way that is being explored is to place semen in the woman’s peritoneal cavity in the hope that sperms will enter the fallopian tubes without being interfered with by antibodies. Evidence that antibodies may be the problem can be obtained by studying what happens when the sperms encounter the mucus in the canal through the cervix. The sperms may be immobilised or destroyed.

Male causes are responsible for infertility in about 30 per cent of couples and sperm defects probably account for a quarter of all cases of infertility. Low sperm counts, provided over half the sperms are mobile when looked at under the microscope, are not as serious a cause of infertility as was once thought. Some such couples can also be helped by the test tube method. Failure to ejaculate sperms is a much less common problem and can be due to the testes failing to produce them or a blockage in the vas or other tubes. One cause of this is a chlamydia infection of the epididymis. In this respect the situation is the same as chlamydia infection leading to later blockage of the fallopian tubes in women.

If sperms are absent and the blockage cannot be relieved, all that can be done is to advise artificial insemination using semen from a donor. Hormonal causes of male infertility are rare.

In the female this is not the case and failures to ovulate account for about a fifth of all infertility. Thanks to recent advances the vast majority of such women can now be made to ovulate. In fact care is needed to ensure that excessive ovulation does not occur. If the fallopian tubes are blocked an attempt can be made to repair them surgically but if this proves impossible the test tube technique can be tried.

Returning to the sperm, actual sperm counts are of less importance these days then they used to be. A few good quality sperms can fertilise an egg but even quite large numbers with some sort of defect may not do the trick. The sperms can look all right and move under the miscroscope but still lack a capacity to fertilise an ovum. Oddly enough this, and other vital properties of the sperm, can be tested by mixing them with hamster eggs and seeing how the sperms perform. In a similar way to sperms, a woman’s eggs can be defective but at present very little is known about this.

Varicose veins adjacent to the testis, a condition known as varicocele, used to be thought to be a cause of male infertility and enthusiastic claims were made about the effects on fertility of treating them. More scientific investigation indicates that it is not a common cause of infertility. Similarly, until recently, endometriosis was thought to be a common cause in women but treating it does not greatly increase the chances of conception so the relationship between the two is not a simple one. However, the test-tube method often results in success with these cases.

A newer variant of the test-tube technique is called GIFT (Gamete Intrafallopian Transfer). Provided the woman has at least one unblocked tube it can be used. The aim is to copy what happens in Nature in which fertilisation occurs at the outer end of the tube. A number of eggs are placed in the fallopian tube along with a prepared sample of sperms. In a third of cases fertilisation occurs and the eggs are slowly wafted along the tubes to the uterus and implant on the uterine wall, as happens when things are left to Nature. The technique is used particularly in cases of infertility for which no explanation can be found and where the test-tube method has failed.

Another technique used is insertion of the husband’s semen into the cervix or into the uterus but this is controversial.

No reader of this book should be surprised to learn that psychotherapy and psychosexual counselling have their successes in cases of otherwise unexplained infertility since the psyche has such a profound effect on the body that some cases of infertility must be due to disturbances between them. From this point of view persuading couples not to become obsessional about their problem but to learn how to enjoy sex can result in apparently dramatic cures. One part of the explanation could be that if the woman learns to have orgasms in intercourse semen may be sucked into her fallopian tubes, thereby increasing her chances of fertilisation. That there is a formidable psychic component to infertility can be judged by the finding that a substantial minority of women conceive after seeing an infertility specialist even long before any treatment is instigated.

Overall, only a minority of infertile couples can be helped. Private specialist climes can often be of more assistance than the NHS but may be costly. The longer the problem goes on the more the chances of success diminish so it is reasonable to consult your doctor if after a year of trying pregnancy has not occurred. However, there are things you can do to help yourselves.

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