and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
Definition
Failure to conceive after 12 months of unprotected sexual intercourse
Incidence
It is said that 15 % of couples have subfertility. This seems to be true for most of the world, unless there are pockets of problems peculiar for a particular population, where the incidence rates can be higher.
Aetilogy and Pathogenesis
Subfertility can be divided into the following potential causative factors (Fig. 16.1):
Fig 16.1
Three basic fertility parameters
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SPERM- The right “number” of sperm have to be deposited, in the right place, at the correct time.
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OVULATION- The woman has to release an egg
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TUBES- The passages, cervix, uterine cavity and tubes have to be patent
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MIXED – more than one factor
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UNEXPLAINED (IDIOPATHIC) SUBFERTILITY
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Transport problem
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Fertilisation problem
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Implantation problem
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Clinical Assessment
History
If possible a couple should be seen together
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Previous fertility history- both partners
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Menstrual history
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Medical History, including cervical smear history
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Surgical History
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Medications including alcohol, recreational drugs, and smoking
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Family History, especially congenital abnormalities, endometriosis
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Social History-
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Sexual History- Intercourse timing and adequacy
Examination
Routine abdominal, speculum and vaginal examination. Opportunistic cervical smear if indicated
Investigations
Female
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Infection screens- Rubella and ?Varicella Immunity (dependent on country)
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Hormones: Mid luteal progesterone and oestradiolIf cycles irregular: FSH, LH, Prolactin, TSH
Male
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Semen analysis on a specimen produced by masturbation
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Antisperm antibodies
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A semen analysis should always be performed before undertaking tubal assessment of the female. If normal, consider tubal assessment
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Hysterosalpingogram (HSG)- (Fig. 16.2) An X-ray contrast test- cheap, widely available, painful, false positives and negatives, limited information.
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