Human fertility is the capacity to produce offspring. In a typical heterosexual couple in their early 30s who are having unprotected sex every two or three days there is a greater than 70% chance of the woman becoming pregnant within one year, and approximately 90% chance of the woman becoming pregnant within four years. A natural pregnancy occurs when sperm from the man, having been ejaculated inside the woman’s vagina, swim through the uterus and along the fallopian tube. Here, they meet an egg which has been released from the ovaries. One sperm, which has already proved itself potentially suitable by getting this far, enters the egg and thereby fertilises it. The egg begins to develop and journeys down the fallopian tube where it implants into the wall of the uterus and grows into a baby. Typically 38 weeks later the baby is born.
What can go wrong?
Although the statistics favour success (and thereby the survival of the human species) the process is complex and has a myriad of obstacles to successful conception and delivery of a child. Some blocks are planned (contraception), others are natural and may require interventions to help overcome them. The implications of fertility issues can have psychological impact. Dealing with unwanted pregnancy, miscarriage, stillbirth, or difficulties getting pregnant can affect a person’s emotional well-being as well as relationships and family/friends networks.
Contraception is intended to prevent fertilisation of an egg by a sperm. Obviously, this can be achieved by not having intercourse. However, the purpose of sex in humans is not just for reproduction of the species, it’s also about pleasure, intimacy and personal expression. Contraception allows sex to proceed (at least in the heterosexual context) by reducing the likelihood of pregnancy. The journey of the sperm can be blocked by a barrier such as a condom (external or internal) or diaphragm. Attempts can be made to reduce the sperm’s chances by withdrawing prior to ejaculation, timing the intercourse to occur during less fertile periods in the woman’s monthly cycle or by interrupting the passage of the sperm from the testes (male sterilisation). The production of the egg (ovulation) can be blocked by chemicals taken into the woman’s body by various means. Most common is the oral contraceptive pill, but it can also be achieved by injections, implants, patches or other slow release systems. It is also possible to interrupt the passage of the egg by blocking the fallopian tubes (female sterilisation). The uterus can be made unreceptive to a fertilised egg using an intrauterine device (sometimes called a coil or IUD). There is also emergency contraception which is intended to prevent pregnancy immediately following unprotected intercourse. This is usually delivered orally as a tablet.
Different forms of contraception have varying success rates and depend upon being used meticulously in line with instructions. The barrier methods also afford some protection from sexually transmitted infection. Even when using contraception, it is possible for pregnancy to occur. The ramifications of this can be complex and distressing and appropriate professional counselling can be beneficial.
Unwanted pregnancy can occur by accident, failure of contraception or by rape. A pregnancy can be ended in different ways depending on how advanced the pregnancy is. This is called an abortion or termination, and in the UK this is provided free on the NHS. Unwanted pregnancies caught early may be terminated by chemicals (the abortion pill) which induce a miscarriage. The other option is a surgical abortion which is a procedure to remove the foetus. After 24 weeks, when a baby is theoretically viable, an abortion is only conducted under specific medical criteria. The decision to end a pregnancy can be distressing and trained psychological support can be beneficial.
Miscarriage and Stillbirth
Even if a person becomes successfully pregnant, about 25% will not go to term. Sometimes a baby does not survive their birth. There may be no clear reasons why, but the loss can be a bereavement and once again, appropriate and professional psychological support can help the bereaved cope with their loss and grief.
What if you are trying to, but not getting pregnant?
The first port of call is usually your GP, who can offer a range of tests to see if there are any obvious problems. The tests can include gonadotropins (Follicle stimulating hormone [FSH] and luteinizing hormones [LH] are the main ones), sex hormones (estrogen, progesterone and testosterone are the main ones) and semen quality (checking for the amount of ejaculate and its consistency, along with sperm count and sperm quality). There are drugs that can stimulate ovulation and further investigations using ultrasound, x-rays or endoscopy (small cameras to look inside) to check for other possible reasons reducing fertility.
NHS or Private?
Up until this point the NHS will probably provide free assistance. If you are still not getting pregnant there is a range of further options available but it can be a postcode lottery whether you can get them on the NHS in your region. Private assisted conception services are available and the sector is stringently regulated by the Human Fertilisation and Embryology Authority (HFEA). It can be an expensive process (several tens of thousands of pounds overall).
There are many explanations why it can be difficult to become pregnant naturally. Reproductive sexual intercourse may not be possible for a variety of reasons, including the difficulties mentioned above, disability or that the relationship is same sex, or the client is single. The type of assisted conception offered will be tailored to the specific circumstances of the presentation and may include: Intrauterine Insemination, where the best sperm can be selected and inserted by catheter directly into the uterus. In Vitro Fertilisation (IVF), where the egg and sperm are brought together in a laboratory (the test tube baby style). Intracytoplasmic Sperm Injection (ICSI) where the sperm is injected manually into an egg. In many cases a donor egg or sperm is required. This raises the question of the identity of the child so produced and the regulation of the donation process. In some cases (for example a male same sex couple) a surrogate mother may be needed to carry the baby. There are complex legal constraints around all these processes so seeking good quality advice is recommended. However, with quality often comes cost and some people choose to travel abroad to seek lower cost and less regulated services.
Still No Guarantees:
Even with the best and most proficient assistance, there are still no guarantees that a successful pregnancy and birth will ensue. Further rounds of assisted conception can be conducted but sometimes it is just not meant to be. In some cases people consider adoption, but there can be constraints and frustrations with this route to parenthood too.
The subject of becoming a parent touches at some of the deepest instincts and insecurities that people have. Dealing with the stress, relationship difficulties along with deep feelings of loss, confusion and despair are an almost inevitable accompaniment to the process, even if assisted conception is not required. Navigating the complex territory of assisted conception and dealing with the financial and emotional burdens can leave people feeling depleted and disorientated. The pleasure potential of a fulfilling sex life can be disrupted.
Appropriately trained, professional counselling support can offer a safe and neutral environment to explore the feelings and implications of any aspect of the process of becoming a parent. It’s not a bad idea to seek out relevant counselling services right at the beginning of the process so that you have a resource to accompany you on the journey ahead.