QuestionSBA
QuestionChoice
Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests. Neither party has any known risk factors for infertility at the moment, which could have otherwise prompted consideration for earlier referral.
53037
a
9 months
QuestionChoice
Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests. Neither party has any known risk factors for infertility at the moment, which could have otherwise prompted consideration for earlier referral.
53039
c
3 months
QuestionChoice
Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests. Neither party has any known risk factors for infertility at the moment, which could have otherwise prompted consideration for earlier referral.
53041
e
6 months
QuestionChoice
Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests.
53038
b
21 months
QuestionChoice
Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests.
53040
d
12 months
QuestionComment
RTFQ!
27236
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subscriber
Sir Pep Guardiola
QuestionComment
math
27252
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subscriber
Nicu Prone
QuestionComment
'They are not related' so random
28406
QuestionComment
actually that question should be part of a full routine obstetric history
43222
User
subscriber
Ale
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Lateral Kinase
QuestionComment
cheeky
62306
User
subscriber
CeCe
Concept
Chapter
# Summary
  
 
Subfertility is defined as the diminished ability of a couple to conceive a child, which may be due to a variety of definable causes or an unexplained failure to conceive over a two-year period. Key signs and symptoms vary based on the underlying cause but generally revolve around the inability to achieve pregnancy despite regular unprotected sexual intercourse. Investigations typically include hormonal studies, semen analysis, and imaging studies. The management of infertility is dependent on the underlying cause and often involves a combination of lifestyle modifications, medical interventions, and assistive reproductive technology. 
  
   
 
# Definition
  
Infertility is the diminished ability of a couple to conceive a child. This may result from a definable cause such as ovulatory, tubal, or sperm problems, or may be an unexplained failure to conceive over a two-year period despite regular (3-4 times a week) unprotected sexual intercourse.
  
 
  
# Epidemiology
  
 
Statistically, a couple stands an 80% chance of conceiving within one year if the woman is younger than 40 years, they do not use contraception, and they have regular intercourse (3-4 times per week). This overall probability increases to 90% if considered over two years.
  
 
# Aetiology

 
Factors affecting natural fertility include:
 
  - Increasing age
  - Obesity
  - Smoking
  - Tight-fitting underwear (males)
  - Excessive alcohol consumption
  - Anabolic steroid use
  - Illicit drug use
  
 

Causes of infertility can be classified into:
  
 
  - **Genetic causes:** This includes Turner's syndrome (XO) and Kleinfelter's syndrome (XXY).
  - **Ovulation/endocrine disorders:** Examples are polycystic ovary syndrome, pituitary tumours, Sheehan's syndrome, hyperprolactinaemia, Cushing's syndrome, and premature ovarian failure.
  - **Tubal abnormalities:** These can be due to congenital anatomical abnormalities or adhesions secondary to pelvic inflammatory disease (often caused by chlamydia or gonorrhoea).
  - **Uterine abnormalities:** These include bicornate uterus, fibroids, and Asherman's syndrome (uterine adhesions).
  - Endometriosis
  - **Cervical abnormalities:** These include cervical damage after biopsy or LLETZ procedure.
  - **Testicular disorders:** Disorders such as cryptorchidism, varicocele, testicular cancer, and congenital testicular defects fall in this category.
  - **Ejaculatory disorders:** These include obstruction of the ejaculatory system and disorders of ejaculation such as retrograde ejaculation and premature ejaculation.
  
 
# Investigations
  
 
Investigations for infertility are divided into those for men and women. 

*For women:*

**Bedside:**
 
- Thorough history, including past medical history, sexual history and details of past pregnancies. 
- Speculum and bimanual examination: To investigate physical anomalies (e.g. large fibroids). 
- STI screen
 
 
**Bloods:**
 
  - Serum progesterone testing (performed 7 days before the end of the menstrual cycle): A rise in progesterone indicates that the corpus luteum has formed and is releasing progesterone due to occurrence of ovulation.
  - Prolactin
  - LH/FSH 
  - Anti-mullerian hormone (AMH): Measure of ovarian reserve
  - TFTs 

 
**Imaging:**
 
- Transvaginal ultrasound scan: To identify any physical anomalies of the uterus, and check antral follicle count (measure of ovarian reserve)
- Hysterosalpingography: Assess tubal patency.
- Laparsocopy and dye: Assess tubal patency in presence of co-morbidities (e.g. PID, ectopic pregnancy, endometriosis). 


*For men:*

**Bedside:**
 
- Thorough history, including past medical history, sexual history and details of past pregnancies. 
- Testicular examination: To investigate visible physical anomalies (e.g. varicocele). 
- Semen analysis: To evaluate sperm count, motility, and morphology. 
 
 
**Bloods:**
 
  - Serum testosterone 
  - LH/FSH 
  - TFTs 
  
 
# Management
  
 
The management of infertility is tailored to the underlying cause but may include:
  
**Conservative:**

  - Weight loss
  - Smoking cessation 
  - Reduction of alcohol intake
  - Stress-reduction strategies

**Medical:**

Medications may be used for ovulation induction, such as: 

  - Clomiphene
  - FSH and LH injections
  - GnRH or DA agonists

  
**Surgical:**
  
  - Assisted reproductive technology, including in vitro fertilisation or intracytoplasmic sperm injection.


In addition to all of the above, if an underlying cause of infertility is found (e.g. fibroids, endometriosis), then those causes should be managed. 


# NICE Guidelines

[Click here for NICE Guidelines on fertility problems](https://www.nice.org.uk/guidance/cg156)

[Click here for NICE Guidelines on infertility](https://cks.nice.org.uk/topics/infertility/)

# References 

[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/498)

[Fields et al., 2023 - BMJ](https://www.bmj.com/bmj/section-pdf/187753?path=/bmj/346/7896/Practice.full.pdf)
929
976
Subfertility
Topic
26
Gynaecology
10668
Couples under 35 should seek fertility evaluation after one year of regular unprotected intercourse without conception.
Presentation
520
Subfertility
UkmlaTopic
18
Obstetrics and gynaecology
A 27-year-old woman attends her GP with difficulty conceiving. She has been having frequent vaginal intercourse without contraception for 3 months with no subsequent pregnancy. She has never been pregnant before and has a regular 29-d cycle. She is not related to her partner and neither of them have any past medical history. They have never received investigation for infertility. On examination, her body mass index is 28.

How much longer should they keep trying to conceive before a referral is made to a local fertility service?
a