Infertility is becoming a growing health challenge facing women in the West.

Rising obesity, insulin resistance and delayed childbearing, along with underlying hormonal and structural conditions, are making female infertility more common and more complex than a decade ago, said gynecologist 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, focusing on polycystic ovary syndrome, or PCOS, which disrupts ovulation.

If no egg is released, pregnancy cannot occur. The condition is strongly linked to insulin resistance, which is often linked to weight gain and metabolic changes, he said.

“Increased BMI causes insulin resistance, elevated androgen levels 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 lifestyle changes are the first step in treatment.

“Lifestyle modification is the easiest way to manage PCOS,” he said. Losing about 10 percent of body weight, quitting smoking and reducing alcohol consumption can restore ovulation in many cases,” he said.

Hormones don’t only fail in the ovaries. Elevated prolactin levels can completely suppress menstruation.

This is often caused by a small pituitary tumor that produces the hormone.

“If prolactin is high, it blocks the menstrual cycle and patients stop having their period,” Ngwenya said. Treatment usually shrinks the tumor and allows the cycle to return.

Thyroid disorders, both underactive and overactive, can also impair fertility until they are controlled.

Then there are the fallopian tubes, where the sperm and egg meet. If they are blocked, fertilization cannot occur, Dr Ngwenya said.

Previous sexually transmitted infections, such as gonorrhea or chlamydia, are a common cause of scarring.

“If the tubes are blocked on both sides, the next step is IVF,” he said, or in vitro fertilization.

IVF is in vitro fertilization, a procedure in which eggs are fertilized outside the body and the embryo is transferred to the uterus.

Some sexually transmitted infections can 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 the 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 presents them.

“Lifestyle and metabolic factors are becoming more common causes,” he said.

Increasing obesity, insulin resistance, smoking and alcohol consumption are contributing to hormonal disorders. Age is another important driver of change. Women are born with a fixed number of eggs. Both quantity and quality decline over time, and after age 35, that decline accelerates.

This increases the risk of spontaneous abortion and chromosomal abnormalities.

Age and lifestyle are important factors.

“Women are delaying motherhood for education and career reasons,” she said. “If someone between the ages of 25 and 30 wants to delay pregnancy, egg freezing is an important option; however, many women only seek help when their bodies have already begun to reduce egg production.”

Not all infertility comes with a clear diagnosis. In some cases, ovulation tests are normal, the tubes are open, the hormones are balanced, and the semen analysis shows no problems, but pregnancy still does not occur. This is classified as unexplained infertility.

“Just because there is no explanation doesn’t mean that nothing bad happens,” he said. “This means our tests cannot identify the cause. That uncertainty can be very distressing.”

When this happens, treatment is usually started conservatively, with ovulation induction and intrauterine insemination.

Intrauterine insemination is a procedure in which prepared sperm are placed directly into the uterus during ovulation to increase the chances of fertilization.

If unsuccessful after several cycles, couples move on to IVF.

“It’s important not to promise results,” Ngwenya said. “Success is never guaranteed.”

Dr Ngwenya said fertility care is not just medical. “Psychological support is very important. It is the first thing we start with,” he said.

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