What is Subfertility?

From the medical point of view, a couple is considered 'sub-fertile' when they fail to conceive after one year of regular, unprotected sexual intercourse.

If the couple has regular sexual activity, what is the chance of pregnancy?

Becoming pregnant is such a complex process that there is a much greater probability of not becoming pregnant during a menstrual cycle than becoming pregnant. Even for fertile couple having regular unprotected intercourse, the chance of pregnancy within one's menstrual cycle is not more than 25%.

Can more frequent sexual intercourse help to increase the chance of pregnancy?

Too frequent sexual intercourse, say once every night, may result in decrease in number of sperm in semen. On the contrary, too infrequent sexual intercourse, say less than once per week, may lower the motility of sperm. Both conditions may adversely reduce the chance of pregnancy. The couple is therefore advised to maintain regular normal intercourse, say two to three times a week, with a slight increase in frequency (such as once every 2 days) around the time of ovulation.

Is Subfertility a common problem?

Yes. It affects 1 in every 6 couples. Subfertility rate increases with female age, particularly in women in their thirties and forties.

Subfertility Factors

Are women accountable for the cause of subfertility?

Both female and male can have problems of subfertility. Epidemiological studies show that female and male factors each account for about 30% of subfertility cases respectively, and the remaining 40% is either suffered from a joint problem or had no cause identified (unexplained subfertility). It has to be emphasized that a combination of female and male problems frequently co-exists, so both couple should be involved during the process of evaluation.

What are the subfertility factors?

♂ Causes of male subfertility: Any unfavorable factors that affect the production or transportation of sperm can lead to male subfertility e.g., smoking, alcohol, undescended testes, varicose vein in the scrotum, or damage of genital tract from previous infection or operation. Besides, recent studies have shown that hereditary factor can be one of the causes to account for no sperm or very low sperm count in some patients.

♀ Causes of female subfertility: Various causes can account for female subfertility, e.g. ovulatory disorders due to hormonal disturbances, pelvic adhesion or blockage of fallopian tubes resulting from endometriosis or pelvic infection /operation, or structural abnormalities of the uterus. Besides, female ageing also affects the natural ability to get pregnant because of the progressive decrease in ovarian reserve.

Unexplained subfertility: If a detailed history and examination followed by complete investigation still fail to give a clear explanation, it is called "unexplained subfertility". In this group of patients, the main factors affecting the chance of conceiving naturally are the woman's age and the duration of subfertility. The natural ability to get pregnant will drop significantly in those women who have advanced age or prolonged subfertility for more than three years.

Scope of Investigation

Doctor will try to answer the following four basic questions to identity the cause of subfertility:

  1. Is there any coital difficulty?
  2. Is there a problem with his sperm?
  3. Is there a problem with her ovulation?
  4. Is there a problem with her genital tract?

If there is coital difficulty, what can we do?

In any case, if a man cannot ejaculate in female's vagina, they are considered to have problem in sexual intercourse. Coital difficulty may result from physical or psychological factors. Couples should seek early assessment as they may resume normal sex life through special treatment and counseling services.

Investigation Methods: Male

How to test the quality of sperms?

Besides detailed medical history and examination, semen analysis is the single most important test in evaluating his fertility. Seminal analysis includes semen volume and acidity, sperm count, sperm motility and sperm morphology. The most common causes of male subfertility are low sperm count, low sperm motility or presence of sperms with morphological defects. In some cases, further investigations such as anti-sperm antibody, sperm function tests, hormonal tests, microbiological assessment of the semen and imaging of the male genital tract may be necessary. However, this should be initiated in the specialist subfertility centre.

Why should we need to collect at least two semen samples?

One of the reasons for abnormal semen analysis is the inaccurate collection of the specimen, or history of recent illness that may affect the production of sperm. Therefore, at least two abnormal samples collected on separate occasions at least 3 months apart are necessary to make a diagnosis of male factor subfertility.

Investigation Methods: Female

How to test ovulation status?

Women who have irregular or absent periods are usually suffered from ovulatory disorders. On the other hand, although regular menstrual cycle usually implies normal ovulation, it is not always true. Some specific test, such as basal body temperature chart, urinary ovulatory kit, or other tests which can detect ovulation, may be required to determine the ovulatory status.

  • Basal body temperature chart:The woman should take oral temperature every morning before she gets out of bed and plot the daily temperature changes. A rise in temperature of about half a degree Celsius around mid-cycle, and maintaining for the remaining days until the next menstruation will suggest that ovulation has occurred.
  • Urinary ovulatory kit:It can detect urinary LH surge and help the couples to plan sexual intercourse around time of ovulation so as to increase the chance of pregnancy.

How to detect female genital tract problems?

It can be detect by the following methods:

  • Ultrasound scan: This is a painless test performed by applying a probe over the abdomen, or by inserting a probe into the vagina. It can detect the abnormalities of the uterus or the ovaries.
  • Hysterosalpingogram (HSG): Blockage of the fallopian tubes and structural abnormality of the uterus may be diagnosed through X-ray examination after injecting dye into the genital tract. This test needs no operation or anaesthesia. However, the disadvantage is that it provides no information on peritoneal diseases such as endometriosis or pelvic adhesion.
  • Laparoscopy and dye studies:The operation is performed under general anaesthesia. It enables the doctor to directly view the surface of the uterus, pelvic cavity, fallopian tubes and ovaries, and can identify pathologies like endometriosis, pelvic adhesion, tubal blockage and ovarian diseases. This is the most comprehensive examination for both the peritoneal cavity and the fallopian tubes, and therapeutic surgery can be performed at the same time.
  • Hysteroscopy:This is usually performed at the same time with laparoscopy. A probe is inserted into the uterus through the vagina. The inner lining of the uterus can be seen. Abnormalities such as intrauterine adhesion or congenital uterine abnormality can be detected.

Treatment Methods

Is subfertility = sterility?

No. After treatment, there is about two-third of couples treated for subfertility will eventually have their own babies. Below are some of the general measures before undergoing treatment:

  • Avoid smoking in both couples
  • Keep body weight normal as significant overweight or underweight will cause difficulty to get pregnant.
  • Proper diet and exercise are important for optimal reproductive function.
  • Make sure woman has rubella antibody

Medical Treatment

For women with ovulatory problem, ovulation induction can be achieved by using oral or injectable hormones to stimulate the growth and release of egg. However, there may be more than one mature egg stimulated resulting in a higher risk of multiple pregnancies.

Surgical Treatment

For women with tubal damage or endometriosis, surgery can be attempted to repair the damage. However, not all cases of tubal damage are amenable to surgical treatment. In cases where surgical correction cannot be performed or failed, in-vitro fertilization should be considered.

Assisted Conception Methods

Intra-uterine Insemination of Husband's semen (IUI)

  • The husband will be asked to produce a semen sample via masturbation. The collected semen is processed in the laboratory to increase the number of motile sperm in normal forms. The doctor will then transfer the processed sperm back to the female uterus matching with her time of ovulation. The procedure requires no anaesthesia
  • This simple procedure is only suitable for couples with coital problem, borderline male problem and unexplained subfertility.

In-vitro Fertilization (IVF)

  • In-vitro Fertilization, also named 'test tube baby', is a method of assisted reproductive technology which involves stimulation of wife's ovaries to produce an optimum number of eggs; retrieval of eggs and sperm from wife and husband respectively; fertilization of eggs and sperm outside the human body in the laboratory; and finally transfer of fertilized eggs (embryos) back to the female uterus.
  • The procedure is usually recommended for women with tubal damage or severe endometriosis
  • Together with intra-cytoplasmic sperm injection, it is the treatment of choice for couples with severe male problem.
  • Up to now, there is no evidence that ""test tube babies"" have a higher chance of congenital abnormalities.

Intra-cytoplasmic Sperm Injection (ICSI)

  • An additional procedure of which a single sperm is injected directly into the egg under microscopic control in the laboratory so as to assist fertilization.
  • This procedure may improve fertilization in cases of severe male factor subfertility or previous history of failed fertilization at IVF

Gamete Intra-fallopian Transfer (GIFT)

  • This method is similar to IVF, except that the eggs and sperm are injected simultaneously into the fallopian tube through laparoscopy in the operating theatre. Fertilization takes place within the body, but not in the laboratory as in IVF.

Artificial Insemination of Donors (AID)

  • The procedure is similar to the intrauterine insemination, except that donor's sperm is used instead of husband's sperm
  • This may fulfill the childbearing wishes of some infertile couples who have no sperm or very poor semen parameters.

Seeking Medical Consultation

Couples should consider seeking earlier medical consultation if they are:

♀ Female: Age at late thirties, three or more miscarriage experience, long and irregular menstrual cycle, short menstrual cycle at three week or less intervals, pain during menstruation or sexual intercourse, history of endometriosis, pelvic infection, and pelvic or ovarian operation.

♂ Male: Had mumps in childhood, history of prostate infection, undescended testis, varicocele, and erectile or ejaculatory problem.

Remarks: Treatment success rate decreases remarkably with increasing female age. Even with the use of advanced assisted reproductive technologies, the success rate for women aged over 45 is more or less equal to ZERO. Do not delay seeking professional help!

Where to Get Help?

1st Step: The basic subfertility evaluation and treatment can be carried out by gynaecologists. FPAHK's Subfertility Service offers investigations for couples who have difficulty in childbearing and can suggest appropriate management.

2nd Step: If there is no identifiable cause for subfertility or if the couples do not conceive after medical or surgical treatment within a given time, they may be referred to a specialist in subfertility centers or an Assisted Reproductive Unit of public or private hospitals.

3rd Step: If all the treatments have failed or the couples are not suitable for treatment, they could either accept to be childless or consider adoption. Further information can be obtained from the Adoption Unit of the Social Welfare Department at 3595 1935.

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