22 Apr 2025 - Service Adjustment of FPAHK Yuen Long Birth Control Clinic (G/F) and Yuen Long FPAHK Anita Mui Health Centre (1/F) from 12 May 2025 (Monday)
31 Dec 2024 - Opening Hours of FPA Birth Control Clinics from January to December, 2025
14 Nov 2024 - The Association is NOT the service provider of FREE HPV Vaccination Catch-up Programme launched by The Department of Health for eligible female Hong Kong residents born between 2004 and 2008.
What is Subfertility?
According to World Health Organization, 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?
Having more frequent sex increase the chance of conception. Reproductive efficiency increases with the frequency of sexual intercourse and is highest when sexual intercourse occurs every 1 to 2 days during the fertile window (five days before ovulation plus the day of ovulation). Generally speaking, too infrequent sexual intercourse, greater than 5 days may adversely affect sperm counts, and if more than 10 days, semen parameters begin to deteriorate. As the fertile window within a given cycle can vary considerably, the couple is therefore advised to maintain regular normal sexual intercourse, say 2 to 3 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 aged over 40.
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 a combination of both and female factors 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 unfavourable 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 etc.. 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 etc.. 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 3 years. Therefore, you should seek medical advice from a specialist as soon as possible.
Scope of Investigation
Doctor will try to answer the following four basic questions to identity the cause of subfertility:
- Is there any coital difficulty?
- Is there a problem with his sperm?
- Is there a problem with her ovulation?
- 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 counselling 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 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, regular menstrual cycle usually implies normal ovulation. Some specific tests, such as basal body temperature chart, urinary ovulatory kit, or other tests which can detect ovulation, can be used to reassure that the women are ovulating normally.
- 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 increase the frequency of sexual intercourse around the time of ovulation.
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.
- HyFoSy (Hystero-salpingo-foam sonography): This test combines the assessment of pelvic organs using transvaginal ultrasound as well as assessing tubal patency by injecting foam material into the uterine cavity. The procedure can be performed in clinic without radiation effect.
- 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: A scope is inserted into the uterus through the vagina. The inner lining of the uterus can be seen. Abnormalities such as endometrial polyp, intrauterine adhesion or congenital uterine abnormality can be detected.
Treatment Methods
Is subfertility = sterility?
No. After treatment, about two-third of couples 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 semen problem or 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.
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 more than 35, three or more miscarriage experience, long and irregular menstrual cycle, short menstrual cycle at 3 weeks or less intervals, pain during menstruation or sexual intercourse, history of endometriosis, pelvic infection or pelvic or ovarian operation.
♂ Male: Had mumps in childhood, history of prostate infection, undescended testis, varicocele, or 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.