Infertility & Subfertility
Infertility is a common and distressing problem, affecting up to 1 in 7 couples.
It can result from female factors, male factors, or both, and often has significant psychological and social consequences.
A structured approach is essential, focusing on history, examination, investigations, and appropriate management.
📖 About Infertility
- Definition: Failure to conceive after 12 months of regular, unprotected intercourse.
- Primary infertility: No previous pregnancy.
- Secondary infertility: Failure to conceive after a previous conception (live birth, miscarriage, ectopic, or termination).
- Has profound emotional and social impact on couples.
⚠️ Risk Factors
- 👩 Female: Age >35, endometriosis, PCOS, PID, previous pelvic surgery.
- 👨 Male: Age >40, varicocele, orchitis, undescended testes, chemotherapy, lifestyle toxins.
- 🍷 Lifestyle: Smoking, alcohol, obesity, poor diet, recreational drugs.
- 🩺 Medical: Diabetes, thyroid disease, autoimmune disorders.
🔎 Causes of Infertility
|
|
| Category |
Examples |
Notes |
| 👩 Female – Ovulatory |
PCOS, hypothalamic dysfunction, hyperprolactinaemia, premature ovarian insufficiency |
Irregular cycles, anovulation |
| 👩 Female – Tubal/Uterine |
PID, tubal damage, adhesions, fibroids, endometriosis |
Blockage or poor implantation |
| 👨 Male |
Low sperm count, poor motility, abnormal morphology, genetic (Y microdeletion, Klinefelter) |
Semen analysis abnormal |
| 🔍 Unexplained |
No identifiable cause after full evaluation |
~25% of cases |
🩺 Clinical Assessment
- 📝 History: Age, duration of infertility, menstrual cycles, coital frequency, contraception, STIs, systemic illness, medications.
- 🧑⚕️ Exam (Women): BMI, hirsutism (PCOS), pelvic exam for masses or tenderness.
- 🧑⚕️ Exam (Men): Testicular volume, varicocele, signs of hypogonadism.
- 💔 Consider psychosocial impact and relationship strain.
🧪 Investigations
- 👩 Women:
– Mid-luteal progesterone (day 21 if 28-day cycle).
– LH, FSH, prolactin, thyroid function, androgens.
– TVUSS (PCOS, ovarian reserve, uterine pathology).
– HSG or HyCoSy (tubal patency).
– Laparoscopy if endometriosis suspected.
- 👨 Men:
– Semen analysis (2–3 samples, ≥3 months apart).
– Hormones: LH, FSH, testosterone.
– Karyotype/genetic testing in azoospermia/severe oligospermia.
– Scrotal ultrasound if varicocele suspected.
- 🧬 Couple: Screen for STIs, HIV, hepatitis B/C before ART.
💊 Management
- 🌱 Lifestyle: Weight optimisation, stop smoking, reduce alcohol, balanced diet, folic acid for women.
- 💊 Medical:
– Ovulation induction: clomiphene, letrozole, or gonadotropins.
– Metformin in PCOS (insulin resistance).
- 🔧 Surgical:
– Laparoscopic treatment of endometriosis.
– Tuboplasty for blocked tubes.
– Varicocele repair in selected men.
- 🧪 Assisted Reproductive Techniques (ART):
– IVF (in vitro fertilisation).
– ICSI (intracytoplasmic sperm injection).
– Intrauterine insemination (IUI).
– Donor gametes or surrogacy if needed.
- 🧠 Psychological support: Counselling, support groups for emotional wellbeing.
📈 Prognosis
- 💊 Ovulatory disorders: Good response to induction therapy.
- 🧬 Male factor infertility: Excellent results with ICSI.
- 🔧 Tubal disease: Variable, improved with IVF.
- 🌍 Unexplained infertility: Many conceive spontaneously or with ART.
📚 References
- RCOG Green-top Guideline No. 12: Fertility Problems – Investigation and Management.
- ASRM Committee Opinion: Diagnostic Evaluation of the Infertile Couple, Fertil Steril. 2021.
- WHO. Infertility definitions and global estimates. 2020.
