Infertility is becoming a growing health challenge facing women in the West.
Rising obesity, insulin resistance and delayed motherhood, along with underlying hormonal and structural conditions, are making female infertility more common and more complex than a decade ago, said gynaecologist Dr Zanele Ngwenya.
The first sign that something is wrong may not be dramatic, but rather month after month of negative pregnancy tests.
“The most common cause we see is ovulatory disorders,” Ngwenya said, zooming in on Polycystic Ovary Syndrome or PCOS, which disrupts ovulation.
If no egg is released, pregnancy cannot happen. The condition is strongly linked to insulin resistance, which is often tied to weight gain and metabolic changes, she said.
“Increased BMI causes insulin resistance, high androgens and hormonal imbalance,” Dr Ngwenya added.
BMI refers to Body Mass Index, a medical calculation that estimates body fat based on height and weight.
Doctors use the Rotterdam criteria to diagnose PCOS. A woman must meet at least two of three markers, which are irregular or absent periods, elevated male hormones either in blood tests or visible through acne and excess facial hair, and polycystic ovaries on ultrasound.
Polycystic Ovary Syndrome a common cause
Dr Ngwenya said that lifestyle changes are the first go-to in treatment.
“Lifestyle modification is the easiest way to manage PCOS,” she said. Losing about 10 percent of body weight, stopping smoking and cutting down on alcohol can restore ovulation in many cases,” she said.
Hormones do not only go wrong in the ovaries. Elevated prolactin levels can suppress menstruation completely.
Often, this is caused by a small pituitary tumour that produces the hormone.
“If prolactin is high, it blocks the menstrual cycle and patients stop getting their periods,” Ngwenya said. Treatment usually shrinks the tumour and allows the cycle to return.
Thyroid disorders, both underactive and overactive, can also disrupt fertility until brought under control.
Then there’s the fallopian tubes, where sperm and egg meet. If they are blocked, fertilisation cannot occur, said Dr Ngwenya.
Previous sexually transmitted infections, such as gonorrhoea or chlamydia, are a common cause of scarring.
“If the tubes are blocked on both sides, the next step is IVF,” she said, or In vitro fertilisation.
IVF is in vitro fertilisation, a procedure where eggs are fertilised outside the body and the embryo is transferred into the uterus.
Some sexually transmitted infections may leave scars
Inside the uterus, fibroids or polyps can distort the lining and prevent implantation. These can often be removed through minimally invasive surgery. Some women are born with structural abnormalities, such as a uterine septum, which can also be corrected.
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Endometriosis, where tissue similar to the uterine lining grows outside the uterus, can affect the ovaries, tubes and surrounding pelvic structures. Severe cases often lead doctors to recommend IVF.
What has changed in recent years, Ngwenya said, is not just the conditions themselves, but who is presenting with them.
“Lifestyle and metabolic factors are becoming more common causes,” she said.
Rising obesity, insulin resistance, smoking and alcohol use are all contributing to hormonal disruption. Age is another major change driver. Women are born with a fixed number of eggs. Both the quantity and quality decline over time, and after 35, that decline accelerates.
The risk of miscarriage and chromosomal abnormalities rises with it.
Age and lifestyle are major factors
“Women are delaying childbearing for education and career,” she said. “If someone between 25 and 30 wants to delay pregnancy, egg freezing is an important option, yet many women only seek help when their bodies have already started lowering egg production.”
Not all infertility comes with a clear diagnosis. In some cases, ovulation tests are normal, tubes are open, hormones are balanced, and semen analysis shows no problem, yet pregnancy does not occur. This is classified as unexplained infertility.
“Unexplained does not mean nothing is wrong,” she said. “It means our tests cannot identify the cause. That uncertainty can be very distressing.”
When this happens, treatment usually starts conservatively, with ovulation induction and Intrauterine insemination.
Intrauterine insemination is a procedure where prepared sperm is placed directly into the uterus during ovulation to increase the chance of fertilisation.
If unsuccessful after several cycles, couples move to IVF.
“It is important not to promise outcomes,” Ngwenya said. “Success is never guaranteed.”
Dr Ngwenya said that fertility care is not only medical. “Psychological support is very important. That is the first thing we start with,” she said.
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