Fertility: Here's what could be delaying conception

Across many cultures, having children is often regarded as a natural step in fulfilling societal expectations, placing an unspoken responsibility on couples to conform.

Yet, there is rarely a defined timeline for when this should occur, and individual circumstances—like professional ambitions or financial preparedness—are frequently overlooked.

It's common for couples to assume that fertility is a given as long as they’re sexually active and not using contraception. However, conception doesn’t always come easily, and fertility challenges can arise unexpectedly. Here’s what every couple should know before starting their journey toward parenthood.

Fertility depends on three key factors: regular ovulation with open fallopian tubes in the female, normal sperm parameters in the male, and regular intercourse to allow the egg and sperm to meet and fertilise.

One often overlooked concept is the chance of conception during a single fertile ovulatory cycle, known as fecundity. This refers to the likelihood of a woman conceiving each month when actively trying.

On average, fecundity is around five percent, meaning that for every 100 fertile women, only about five will conceive each month. This highlights that couples need to make consistent efforts over time to achieve successful conception.

How often should a couple attempt conception?

Many people attempt to improve their chances by timing intercourse around ovulation. However, this approach is often misguided because the visible signs of ovulation usually appear after the egg has already been released.

Since a female egg has a short lifespan—about 24 hours—after which it rapidly dehydrates and breaks down, relying solely on ovulation signs can reduce the chances of conception.

Fortunately, nature has compensated for this by enabling sperm cells to remain viable within the female reproductive tract for several days.

Therefore, couples are generally advised to have intercourse two to three times per week to maximise their chances of conceiving.

However, the standard timeframe for trying to conceive is considered to be 12 months, during which approximately 85 percent of couples are successful.

At what point should you worry about conception?

When couples worry that something might be interfering with their ability to conceive, the underlying issue is occasionally apparent.

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More often, however, the cause is unknown to them. A consultation with a healthcare professional can help clarify the situation by exploring relevant factors and recommending appropriate tests.

Attending this appointment together can help dispel fertility myths, foster mutual understanding, and strengthen their commitment to treatment. It also creates an opportunity to refer them to valuable support services, including counselling.

What does the doctor examine to diagnose fertility challenges?

A comprehensive assessment of fertility includes examination of a semen sample to check for correct sperm parameters, testing ovulation and lastly checking the patency of fallopian tubes.

The sequence of testing should be logical enough to allow prompt arrival at the right diagnosis and avoid unnecessary testing.

Overall, half of fertility issues may be related to sperm and the other half to female factors, including ovulation and tubal blockage. The medical approach, therefore, would be to start the investigation with the least invasive tests, that is, semen analysis and ovulation check.

This means that if the sperm parameters are normal, then assessing to check that the fallopian tubes are open is the next logical step, as this helps to determine whether a chance of natural conception exists.

The commonly performed test for tubal patency involves passing a special dye through the tubes and taking an X-ray film. This is known as hysterosalpingogram or HSG. To avoid exposure to radiation (X-rays) and a separate examination with ultrasound scanning, a novel test known as HyCoSy is now available.

HyCoSy involves having an ultrasound scan to look at the uterus and ovaries (information not gained from HSG) and then passing a special dye through the tubes to check patency at the same time.

This avoids multiple visits and can be done at any time of the cycle. It is far more comfortable than HSG, though it requires a specially trained practitioner to perform.

What fertility treatment options are there?

Generally, a couple feel more reassured and ready to engage with treatment when their experience is enhanced by an empathetic team who are ready to give as much information and allow shared decision making, respecting values and opinions. It may be exasperating going through fertility investigations and may be a roller-coaster experience.

Whereas knowing the factors contributing to subfertility is important, particular diagnoses can be devastating, such as blocked fallopian tubes, severe sperm abnormalities and ovarian failure.

Couples may feel frustrated, angry and could tend to want to blame certain situations in their own life experiences. Relationship strain may also occur. This is the moment where the health care team should be very supportive and also engage counselling services.

Options for fertility treatment should then be discussed sensitively, paying attention to the individual couple's circumstances and offering information based on current best evidence.

A greater majority of couples may require assisted reproductive treatment, such as in vitro fertilisation (IVF). This is usually a major decision for a couple to make as it involves financial commitment, uncertainty about success and risks that come with this.

It is important that a couple have factual and up-to-date information in an easy to understand rubric. They should never feel rushed to undertake this treatment and counselling support is crucial to making this decision. It helps a great deal when both partners attend the clinic for these discussions.

Sometimes, effective treatment is faced with certain barriers or constraints. It should never feel like the end of the road for the couple, as other options must be explored.

These include discussing the use of donor gametes or alternative parenthood options such as adoption, foster parenthood or use of surrogacy arrangements. It calls for an empathetic fertility specialist to navigate these issues.

Whereas individuals may have various coping strategies, it is important for the couple to have family support and also support groups such as Waiting Wombs Trust. Legal opinion may need to be sought in some circumstances.

The writer is a Consultant Fertility Expert at Aga Khan University Hospital, Nairobi