What is Subfertility?

Subfertility usually defined as the inability of a couple to achieve pregnancy after one year of unprotected sexual intercourse.

We usually begin investigation for a cause of subfertility

• If you have been trying to conceive for a year or more
• After six months if you are 35 years or older, so as to minimize unnecessary delays in treatment
• Earlier if there is reason to suspect an underlying problem, e.g. with irregular periods or known fertility problems

How common are fertility problems?

• One in seven couples has problems conceiving
• Six in every 100 women attending the Gynaecology clinics at the QEH attend for fertility evaluation

So you and your partner are not alone, and the various emotions you are experiencing are quite normal. With evaluation, you may find pregnancy more obtainable. At ObGyn Total Care we currently can offer help to those who ultimately require treatment which does not require tertiary level assisted reproduction treatments – that is, we do not yet offer In Vitro Fertilization (IVF) (“test tube babies”). That said, local fertility audits suggest that many couples can be helped by the services we provide.

How does pregnancy naturally occur?

First, the ovary, which contains your eggs, must release one of them, or ovulate. The fallopian tube picks up the egg. Sperm must travel through the vagina, and through the uterus and into the fallopian tube to fertilize the egg. The fertilized egg will become an embryo (which will eventually become your baby), and this travels down the tube to the uterus, where it implants and grows.

Can you explain more about fertility factors?

Ovulation problems account for 25% of subfertility cases. During ovulation, a mature egg is released from one of your ovaries. You are probably ovulating if you have regular periods, and a 24 to 34 day cycle. You are less likely if your periods happen every few months or not at all. After ovulation, the level of a hormone called progesterone rises in your blood, and is highest at about seven days later. Your doctor may request that you do a blood test between day 19 to 23 of a 28 day cycle to confirm ovulation. He/she may also do other tests to determine why you may not be ovulating, before prescribing medications to try to help.

Tubal factor accounts for 35% of fertility problems. Fallopian tubes need to be open and functional in order for one to conceive. It may be necessary to test whether your tubes are open (patent). A hysterosalpingogram (HSG) is an X-ray test where dye is injected through your cervix, uterus and fallopian tubes, and where free spill indicates patency. The ultrasound equivalent is called hystero-contrast sonography (HyCoSy). No spill implies blockage. A similar test can be carried out using laparoscopy (camera surgery), where occasionally some problems can be fixed at the same time. Severely damaged tubes will require IVF.

Male factor accounts for 40% of fertility problems (male alone or contributing). It is therefore crucial that your partner has a semen analysis done during testing. This will require 3 days of abstinence, and collection of a sample into a container provided by the laboratory, who will examine the semen under a microscope for amount, movement and sperm appearance and shape. Occasionally more than one sample may be needed, and male problems can sometimes require evaluation by a urologist. Direct injection of a sperm into an egg (ICSI, intracytoplasmic sperm injection) may be used as part of an IVF process.

Age: As you get older, fertility declines, because of fewer eggs, and reduced quality. It becomes more difficult to become pregnancy, and miscarriage becomes more likely. Blood tests such as follicle-stimulating hormone (FSH), done on day 2, 3 or 4 of your period, check your “ovarian reserve”, or age-related fertility potential. An elevated FSH indicates lower chance for pregnancy, particularly over age 35. Antral follicle counts (on ultrasound) and anti-mullerian hormone (AMH) are other options for checking ovarian reserve.

Peritoneal Factor: Sometimes women have difficulty becoming pregnant due to adhesions (scar tissue) or endometriosis (a condition in which tissue similar to that normally lining the womb is present outside of the womb). Laparoscopy can sometimes help remedy these problems.

Unexplained Subfertility: This affects 10% of couples; in such cases all tests are normal and there is no easily identifiable cause. These may have genetic, tubal function, sperm function or egg quality problems that are difficult to diagnosis and/or treat. Many of these cases will need IVF.

Is there anything we can do to improve our chances?

• Having sex every 2 to 3 days optimises the chance of pregnancy
• Stopping smoking and alcohol use improves chances
• Both partners should maintain a normal body weight
• Avoid high temperatures around the testes
• Avoid exposure to chemicals and unnecessary medications
• Ladies, start a Folic acid containing vitamin to reduce baby brain and spinal cord abnormalities should you become pregnant

Further Information online: ASRM, WebMD, NHS Choices

Sources: ObGyn Total Care information leaflet “For couples attempting pregnancy”; QEH Fertility Audit – West Indian Medical Journal  http://dx.doi.org/10.7727/wimj.2016.006