Majority of couples conceive without difficulty or undue delay. However one in six to seven couples may experience problems and this is generally termed medically as ‘Subfertility’. The definition basically means difficulty in conceiving despite having regular unprotected sexual intercourse for two year. However treatment is usually commenced after one year of subfertility. This does not include couples / partners who have sexual dysfunction resulting in being unable to consummate or maintain an erection or have an ejaculation.

One of the main reasons for dropping in fertility is because couples defer starting a family to a later age. This is an important factor for women. The fertility rate drops with increase in age. For women aged 35 till 39 years the chance of conceiving is about half that of women aged 19 till 26 years of age.

Causes

Among the causes for subfertility are problems related to ovulation, the fallopian tube structure and uterine cavity distortion. Ovulation problems can be due to polycystic ovarian syndrome, hormonal disorders (high prolactin level, abnormal thyroid level), premature menopause, underweight or overweight, chronic illness, ovarian surgery. In relation to the fallopian tube, it could be due to blockage or damage. This could be a result of infection (sexually transmitted disease), previous surgery or endometriosis.

Among men the problem is usually with abnormal sperm levels. The abnormality could be in the number of sperm count, sperm movement and/or sperm form. This is either a result of congenital abnormality, hormonal problems, infection of the testes (eg chicken pox, mumps), undescended testes, exposure to radiation or chemicals, smoking, overweight, varicocele.

In a proportion of couples there can be no identifiable cause and are grouped as unexplained subfertility. Stress can also be factor but it is difficult to categorise.

Couples should seek medical advise after two years of subfertility as further delay would cause fertility rates to drop among women and / or worsen any pre-existing medical condition.

Treatment

Some basic investigations can be done by general practitioners. This includes semen analysis (sperm test) for the male partner, and hormonal test on day 21 of her menses if she has regular 28 day cycles for ovulation among women. If any abnormality are found on clinical examination or investigation patient should be referred to a reproductive medicine specialist. Here further assessment of the fallopian tubes, uterine cavity, etc would be done. It could be done either using ultrasound imaging (via transvaginal scan), radiological imaging such as hysterosalpingogram (HSG) or minimal invasive surgery (laparoscopic or hysteroscopic surgery).

Treatment options would include ovulation induction with fertility medications and monitoring by ultrasound scan, artificial insemination programmes using husband’s sperms, and some may need advanced medical techniques. These techniques include in-vitro fertilization (IVF)(test-tube baby) where eggs are fertilized in the laboratory and resulting embryos are transferred back into the uterus. Intra-cytoplasmic sperm injection (ICSI) means fertilization of an egg is achieved by injecting a single sperm into the egg. Testicular sperm aspiration / extraction means sperms are obtained surgically from the testis in males or husbands where the sperm quality and numbers are very low or absent. Reversal of female sterilization is an option for those women who had tubal ligation done.

Precautions to be taken

• Practice healthy life style, stop smoking / drug abuse. Exercise, maintain ideal body weight, try to eliminate stressful activities and limit alcohol intake. Avoid or protect oneself from sexually transmitted disease.
• Have intercourse during fertile period (day 10 till day 16 menses) would increase pregnancy chances.
• Seek early medical treatment for menstrual irregularities for women.
• Communicate fears and emotions to your partner on regular basis and support each other.
• Men should avoid tight undergarments and lounging in sauna or hot bath.
• Seek early treatment for gynaecological / medical illness and ensure compliance to treatment for chronic illness such as diabetes, hyperthyroidism, etc.