Considered by the World Health Organization (WHO) to be a "major health challenge" infertility is a growing concern as birth rates fall in Western countries. In Switzerland, about one in six adults experiences difficulty having a child in their lifetime. Is there cause for alarm? Dr Isabelle Streuli, senior physician and head of the Reproductive Medicine and Gynaecological Endocrinology Unit at Geneva University Hospitals (HUG), weighs in.

Several factors come into play when it comes to the fertility problems that couples can face. However, a woman’s age is the most crucial factor, as the quantity and quality of eggs decline dramatically as the years pass. These days, women decide to have children later and later, which mathematically increases the challenges of getting pregnant. After age 40, a woman’s risk of infertility – defined as the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse – is multiplied by six.

Men’s age also plays a role, but to a lesser extent. That said, in most cases infertility results from an accumulation of several small factors that affect both men and women. When combined, they reduce the chance of pregnancy. Overall, around 30% of infertility cases involving a couple are linked to the woman, 30% to the man and 20% to both. Therefore, women alone are not to blame! The remaining 20% includes infertility problems due to unidentified causes. And that is very hard for the couple to accept. They want a clear answer to their problem, and we can’t always give them one.

In women, infertility can be caused by ovulation problems, fallopian tube damage, diseases such as endometriosis, or problems relating to sexuality, such as the inability to have sexual intercourse. In men, it involves sperm count or sperm motility. But it’s important to note that infertility does not necessarily mean sterility, because fertility varies naturally over time. Sperm count in semen fluctuates. Ovulation can be irregular and does not always occur at the same time in the menstrual cycle. After one year, around 15% of couples are unable to procreate naturally and are therefore considered infertile. By trying for a second year, without taking any special measures, this figure drops to 7%. Some couples who are unable to have children naturally would eventually get pregnant down the road if they kept trying. In English, they refer to this as "subfertility" rather than infertility. However, difficulty in getting pregnant causes significant psychological distress, and it has a serious impact on the relationship and the couple’s sexuality. That is why it’s important to seek out special medical help.

For the most part, we don’t know what the causes are, but scientists suspect it’s connected to chemical exposure, especially to endocrine disruptors. The drop is worrying because we don’t know when it will stop. But, in terms of fertility, we’re still above the WHO fertility threshold of 20 million sperm per millilitre.

Apps are widely used by couples to track fertility windows, but no scientific study has proven that they’re effective. What’s more, they all have different algorithms, but I think some of them work well with women who have very regular menstrual cycles. But these people need them the least. As for urine ovulation tests, they improve the chances of pregnancy for women under 40 who are not infertile. There again, these are the people who need them least.

First, we will look for the causes of infertility and then, depending on the diagnosis, propose appropriate solutions. The first step is to recommend lifestyle changes, since factors such as obesity, exposure to toxic substances (tobacco, alcohol) or excessive exercise can have a deleterious impact on the chances of achieving pregnancy. Medical treatment will then be proposed. In certain cases of endometriosis or deformation of the uterine cavity by myomas, we may resort to surgery. In cases of ovulation disorders, hormonal treatment may be administered, with or without artificial insemination, provided that there are no severe spermogram disorders. In many situations, particularly where there is damage to the fallopian tubes, severe endometriosis or severe male dysfunction, in vitro fertilisation is the preferred option. Sperm donation is a possible option in the case of severe male disorders, particularly in the absence of sperm.

There have been many. Intracytoplasmic sperm injection (ICSI) was introduced in the 1990s and has made it possible for men with severe oligoasthenospermia – decreased sperm concentration and sperm motility – to try IVF with their partner. Preimplantation diagnosis of diseases (PGD-M), which has been authorised in Switzerland since 2017, enables couples suffering from or carrying a rare and serious genetic disease to avoid passing it on to their child. PGD-A (pre-implantation diagnosis of aneuploidies, i.e., abnormalities in the number of chromosomes) is aimed at couples undergoing IVF, and ensures that only embryos with the correct number of chromosomes are placed back in the womb, thereby improving the chances of pregnancy and reducing the risk of miscarriage. Demand for PGD has risen sharply since this treatment was first authorised in Switzerland in 2017. Fertility preservation (gamete cryopreservation) is also developing. This field uses a technique called vitrification, which consists in immersing oocytes directly in liquid nitrogen at -196°C to freeze them. It has been a major innovation, since it offers better results than the slow cryopreservation used in the past.

Over the next few years, several other innovations could improve patient care, including non-invasive PGD. This involves genetic testing on the follicular fluid, instead of removing embryonic cells. Robotisation and automation are also being used more and more with MAR technologies.

Unlike hormonal stimulation or artificial insemination, IVF is not covered by mandatory health insurance in Switzerland. That’s the limit. Some couples simply cannot afford this treatment. It is relatively expensive, and it often takes several IVF cycles before achieving pregnancy.

They should be wary of the prices advertised on websites, because you don’t always know what’s included. The bill often sky-rockets after the fact, due to all the tests and medications that are added. It’s true that IVF is more expensive in Switzerland. But that’s because it’s a complex treatment that requires many hospital and laboratory specialists, and salaries are higher here.

In some countries, fertility has become a big business with medically assisted reproduction centres whose aim is purely commercial. Patients are sometimes hostage to this system, because once you’ve started treatment to become a parent, it’s very difficult to stop before you’ve actually become pregnant. This pushes some patients to try multiple IVF cycles and go into debt. To deal with this situation, we try to maintain our role as doctors. We talk to patients and present them with all the options. If, for example, a woman needs an egg donation to make her wish of getting pregnant a reality, we inform her that she cannot do it in Switzerland but that the technique is available elsewhere. On the other hand, surrogacy is a different matter. Swiss law is much more restrictive, and intermediaries can even go to prison. So we cannot advise our patients to seek surrogacy abroad.