Female infertility: when IVF is not the answer

IVF is one of the great achievements of modern medicine and has helped millions of couples have a child. But it is not the only answer to infertility. Many causes of female infertility can be treated successfully with medication, surgery, or simple lifestyle changes — and the couple can conceive naturally.

How does the work-up for infertility start?

Before any treatment is decided, a clear diagnosis is needed. The basic work-up includes: assessment of the cycle (ovulatory or not), hormonal testing (AMH, FSH, oestradiol, thyroid hormones, prolactin), ultrasound of the uterus and ovaries, tubal patency assessment (hysterosalpingography), and the partner’s semen analysis. The cause — and the appropriate treatment — emerges from the overall picture.

Ovulation disorders

Many women have cycles without ovulation. The most common cause is polycystic ovary syndrome (PCOS). Other, rarer causes include thyroid dysfunction or hyperprolactinaemia, both of which can be detected by a blood test and corrected.

In women with PCOS, first-line treatment is lifestyle change (weight loss where needed) and, if that is not enough, oral letrozole for ovulation induction — which outperforms clomiphene citrate in live-birth rates. In the rare cases where medication fails, laparoscopic ovarian drilling may be performed. In most women IVF is not needed.

Endometriosis

Endometriosis reduces the chance of natural conception through several mechanisms — pelvic inflammation, reduced ovarian reserve where endometriomas are present, impaired endometrial receptivity, and — in advanced disease — adhesions that prevent the fallopian tube from picking up the oocyte. In younger women with minimal-to-moderate endometriosis, laparoscopic removal of the lesions increases the chance of natural pregnancy. In women of advanced reproductive age, where time is limited, IVF is the faster route.

Fibroids

Fibroids are benign tumours of the uterus. Not all of them need to be removed. Subserosal fibroids (outside the uterus) do not affect fertility. Submucosal fibroids (inside the uterine cavity) reduce implantation, and hysteroscopic removal improves pregnancy rates. Intramural fibroids (within the uterine wall) are assessed case by case: when they distort the uterine cavity, removal is recommended; when they do not, evidence for the benefit of removal is insufficient and the decision is individualised.

Tubal occlusion

For natural pregnancy to occur, the fallopian tubes must be open and functional. Infections (most often from chlamydia), endometriosis, or previous pelvic surgery can block them. Today, when the tubes are affected, IVF is the most effective option — laparoscopic tubal repair has lower success rates and is reserved for select cases. When there is a hydrosalpinx (a dilated tube filled with fluid), salpingectomy or laparoscopic tubal occlusion before IVF significantly improves pregnancy rates — the tubal fluid is considered toxic to the embryo.

Lifestyle

Smoking, excess alcohol, and a body weight that is either too high or too low all reduce the chance of pregnancy and increase the risk of miscarriage. In overweight women, a 5–10% reduction in body weight is often enough to restore ovulation and allow natural conception. In women with very low weight, periods can become irregular or stop — weight gain often restores the cycle.

Does stress and psychology play a role?

The stress of a single IVF cycle does not appear to meaningfully reduce the chance of pregnancy. Chronic infertility-related stress, however — and major life events such as bereavement or job loss — can affect fertility indirectly, by leading to behaviours that do not help it (smoking, weight gain). Psychological support mainly helps the couple live the journey better; recent evidence also shows a small but real improvement in pregnancy rates from interventions such as CBT and mind-body approaches.

How much does age matter?

The woman’s age is today the single most important prognostic factor in any fertility treatment — and the only cause that cannot be reversed. After the age of 35, fertility declines steadily; after the age of 40, it falls sharply. When a woman is approaching or has passed 38, even when the underlying problem could be managed conservatively in a younger woman, IVF becomes the more obvious choice — mainly because time is not on her side.

IVF is not the only answer to infertility. Most causes have simpler solutions that can lead to natural conception — as long as we don’t run out of time.