Infertility is said to occur when a couple have regular unprotected sexual intercourse of reasonable frequency and are still unable to conceive after one year. A great number of couple will conceive within one year, the remaining small percentage will conceive in the second year. However, evaluation starts after one year for younger women, those ≥35years should be evaluated after 6months of trying to conceive.

The shorter period for evaluating older women has to do with the reduction in the quality of their eggs with age. This affect their chance of conception and also increase their risk of having babies with congenital malformation. A woman’s ability to conceive reduces as she ages.

The period of evaluation will involve extensive history into the sexual and medical history of the couple. The history and examination alone may reveal the cause of the infertility. Both couple are encouraged to attend at least the first consultation. This is where they will be educated on the fertile period where conception is highly likely and also to avoid use of oil based lubricant. This is also an opportunity to commence pre-conception counselling and care.

It is worthy of mention that no sex position increases the chance of conception. Also, there is no need for the women to remain lying either face down or up after intercourse. This does not affect the ability of the sperm to get to the egg. It is also normal to see some seminal fluid coming out of the vagina after sex. The fluid must have serve their purpose; providing the medium for the sperm to swim up to the egg.

As already mentioned in the first article of this series, a couple’s inability to conceive maybe be from one partner or contributed equally by both of them. In certain couples, the cause is not known and this is called unexplained infertility. While the cause of infertility could be sex specific, some of the causes can be found in both sexes.


For a man to successfully get a woman pregnant; the testis must be in a state of good health to produce adequate, healthy, motile sperm, the vas deferens must be patent to conduct the sperm and he must be able to achieve erection and ejaculate into the woman’s vaginal. The following are some of the causes of male infertility;

Hormonal disorders: male infertility could result from been born with the absence of the hormone gonadotrophin releasing hormone. The pituitary gland could fail either from the effect of a tumour, radiation or surgery resulting in infertility. Other hormonal causes of male infertility include; thyroid disease, diabetes and high blood prolactin level.

Abnormality of sperm formation: small deletion of one or all the three region on the Y-chromosome that controls the process of sperm formation call spermatogenesis will result in infertility. This deletion could be so small that it may not be detected on karyotyping. Affected males will have reduced sperm or no sperm at all. This may progress from reduced to total absence of sperm resulting in secondary infertility. Other causes of abnormal sperm formation are; mumps infection of the testis, exposure to radiation and testis that fails to descend to the scrotum.

Abnormality of sperm movement: some individuals could be born with defective cilia (Kartagener syndrome); this manifest as male infertility with chronic respiratory infection due to absence of the cilia needed to clear mucus. This also affects the ability of the sperm to move.

Abnormality of sperm passage: some individuals may be born without a vas deferens or their vas deferens may be obstructed later.

Varicocele: the veins in the scrotum are dilated and could give the sensation of a ‘bag of worm’ when felt. This is believed to cause infertility by increasing the temperature in the scrotum. The scrotum by God’s design was kept outside the body for a reason; to have a temperature far less than that of the body. The scrotum need to be at the right temperature for sperm production, motility and proper structure and varicocele interferes with these. Varicocele could manifest with scrotal discomfort or pain.

Sexual dysfunction: reduce sexual desire, retrograde ejaculation (backward emission of semen into the bladder) and erectile dysfunction (inability to achieve and sustain penile erection sufficient for sexual satisfaction) result in infertility. Erectile dysfunction could result from alcoholism as it inhibits sexual response by interfering with testosterone production.


For a female to successfully conceive; ovulation must take place, the egg picked up by a fallopian tube, fertilization must occur, transport of a fertilized egg to the womb and implantation of the zygote into the womb. Anything that interferes with this process or passage of sperm into the female genital tract will cause female infertility. The following are some of the causes of female infertility;

Cervical causes: abnormality of the cervix could result from infection, surgical procedure or exposure to radiation. These can result in abnormal narrowing of the cervix or alteration in the production of cervical mucus. The cervical mucus helps the sperm to undergo the changes necessary to penetrate the egg. Some medication such as hormonal contraception, thickens the cervical mucus interfering with sperm passage.

Uterine causes: uterine adhesion from infection, D & C, fibroids in the inner lining of the womb and fibroid removal surgery may result in a partial or complete closure of the cavity of the womb. This interferes with the implantation of the fertilized egg. The uterus may be absence in certain instance or badly malformed in a way that it interferes with implantation.

Ovarian causes: the ovaries may be absent or present but fails to release eggs. Ovulatory dysfunction could result from some endocrine conditions like; thyroid disease, polycystic ovarian syndrome, pituitary disorders (resulting in high prolactin or deficiency of the follicle stimulating and luteinizing hormones), disorder of the hypothalamus resulting in gonadotrophin releasing hormone(GnRH) insufficiency. Other conditions could also alter the release of the GnRH such as high level of stress, starvation, malnutrition, chronic diseases (liver disease, renal failure).

Fallopian tube causes: fertilization takes place in the fallopian tube. The fallopian tubes may be absent or blocked due to infection or from effect of other pelvic tumour. Smoking also interferes with the ciliary action of the cells needed to pick up and move the release egg.

Pelvic causes: pelvic adhesion from previous pelvic surgeries, pelvic inflammatory disease or endometriosis (when the inner lining of the womb is also found outside) can block the fallopian tube or interferes with it motility.

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