Subfertility

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. 

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. 

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.

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.

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.

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.