Subfertility

Table of Contents

Introduction

Subfertility, also known as sub fecundity, refers to a condition where a couple experiences difficulty in achieving conception despite regular unprotected sexual intercourse for a considerable period, usually defined as one year. Unlike infertility, which implies a complete inability to conceive, subfertility suggests a delay or reduced likelihood of achieving pregnancy. Several factors contribute to subfertility, and its management often involves a comprehensive assessment and targeted interventions.

Subfertility, also referred to as sub fecundity, is a condition characterized by difficulties in achieving conception despite regular, unprotected sexual intercourse for an extended period, typically defined as one year. Unlike infertility, which implies a complete inability to conceive, subfertility suggests a delay or reduced likelihood of achieving pregnancy. Both male and female factors can contribute to subfertility, encompassing issues such as irregular ovulation, hormonal imbalances, structural abnormalities, sperm disorders, and age-related declines in fertility. The management of subfertility involves a comprehensive diagnostic evaluation to identify the underlying causes, followed by targeted interventions such as hormonal treatments, assisted reproductive technologies (ART) like in vitro fertilization (IVF), intrauterine insemination (IUI), lifestyle modifications, and, in some cases, surgical procedures. The goal is to address specific factors contributing to subfertility and enhance the chances of successful conception and a healthy pregnancy.

Subfertility Factors in Males

Male subfertility refers to conditions where a man experiences difficulties in contributing to conception, leading to challenges in achieving pregnancy with a female partner. Various factors can contribute to male subfertility, affecting sperm production, quality, or delivery. Here are common factors associated with male subfertility:

Low Sperm Count (Oligospermia): Low sperm count, defined as having fewer than 15 million sperm per milliliter of semen, can reduce the likelihood of fertilizing an egg. Oligospermia is a common contributor to male subfertility.
Poor Sperm Motility (Asthenospermia): Sperm motility refers to the ability of sperm to move effectively. Poor sperm motility, known as asthenospermia, can impede the sperm’s ability to reach and fertilize an egg.
Abnormal Sperm Morphology (Teratospermia): The shape and structure of sperm, known as sperm morphology, play a crucial role in fertility. Abnormalities in sperm morphology, termed teratospermia, can impact the sperm’s ability to penetrate the egg.
Erectile Dysfunction: Conditions that affect a man’s ability to achieve or maintain an erection, such as erectile dysfunction, can hinder successful intercourse and contribute to subfertility.
Varicocele: A varicocele is the enlargement of veins within the scrotum. It can lead to increased testicular temperature, which may negatively impact sperm production and quality.
Hormonal Imbalances: Hormonal imbalances, including deficiencies in testosterone or imbalances in hormones like FSH (follicle-stimulating hormone) and LH (luteinizing hormone), can affect sperm production and maturation.
Genetic Factors: Genetic conditions, such as Klinefelter syndrome, can result in abnormal development of the testicles and impact fertility.
Obstruction of Reproductive Tract: Blockages or obstructions in the reproductive tract, such as the vas deferens, can prevent the normal flow of sperm during ejaculation.
Infections: Infections of the reproductive organs, such as epididymitis or sexually transmitted infections, can affect sperm production and function.
Environmental Factors: Exposure to environmental factors like excessive heat, radiation, toxins, or certain medications can have adverse effects on sperm production and quality.
Lifestyle Factors: Lifestyle choices, including smoking, excessive alcohol consumption, drug use, and obesity, can contribute to male subfertility.

Management of male subfertility involves a comprehensive evaluation by a healthcare professional, typically a urologist or reproductive endocrinologist. Treatment options may include addressing underlying medical conditions, lifestyle modifications, assisted reproductive technologies (ART), or surgical interventions, depending on the specific factors identified. Additionally, counseling and support may be provided to address the emotional aspects of male subfertility.

Subfertility Factors in Females

Female subfertility refers to conditions where a woman experiences difficulties in conceiving or carrying a pregnancy to term. Various factors can contribute to female subfertility, affecting different aspects of the reproductive process. Here are common factors associated with female subfertility:

Ovulatory Disorders: Irregular or absent ovulation, a condition known as anovulation, can significantly impact fertility. Disorders such as polycystic ovary syndrome (PCOS) can contribute to ovulatory issues. Genetic abnormalities, like hypogonadism or Turner’s syndrome, can result in the absence of ovaries, leading to an inability to produce egg cells. Hormonal imbalances, such as hypothyroidism, disrupt the intricate communication between the ovaries, hypothalamus, and pituitary gland, preventing the ovaries from generating egg cells.
A woman’s overall nutrition, weight, and exercise routine also play a crucial role in ovulation. Elevated blood glucose levels, often associated with dietary factors such as easily digestible carbohydrates, excessive protein, and saturated fats, can disturb the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), ultimately causing ovulation failure.
The types of food a woman consumes have a direct impact on her fertility. Diets rich in easily digestible carbohydrates and excessive protein, as well as those high in saturated fats, are associated with decreased fertility. Stress is another significant factor influencing anovulation. Stress interferes with the secretion of gonadotropin-releasing hormone (GnRH) and lowers the production of LH and FSH, disrupting the normal ovulatory process.
Polycystic ovary syndrome (PCOS) stands out as the most common cause of anovulation in women. In this condition, the ovaries produce excess testosterone, leading to a reduction in the production of FSH and LH. Consequently, women with PCOS often experience infrequent ovulation, sometimes only a few times throughout the year.
Age-Related Decline in Fertility: As women age, the quantity and quality of their eggs decline, leading to a natural decrease in fertility. Advanced maternal age is associated with a higher risk of subfertility and pregnancy complications.
Uterine Abnormalities: Structural abnormalities in the uterus, such as uterine fibroids, polyps, or congenital malformations, can interfere with implantation and the ability to sustain a pregnancy.
A rare condition impacting a woman’s fertility involves the presence of tumors in the uterus, which can potentially obstruct the implantation site for the embryo. Another contributing factor to subfertility is endometriosis, where particles of the uterine endometrium regurgitate and proliferate, and creating obstacles for the embryo during implantation.
Insufficient secretion of estrogen and progesterone from the ovaries leads to inadequate formation of the endometrium, causing interference in the growth of the embryo. This hormonal imbalance can further contribute to difficulties in achieving successful implantation and subsequent pregnancy.
Tubal Factors: Blockages or damage to the fallopian tubes can impede the journey of the egg from the ovary to the uterus, hindering fertilization.
Endometriosis: Endometriosis is a condition where tissue similar to the lining of the uterus grows outside the uterus. It can cause pelvic pain and interfere with fertility by affecting the function of reproductive organs.
Pelvic Inflammatory Disease (PID): Infections, particularly untreated or recurrent pelvic inflammatory disease, can lead to scarring and damage to the reproductive organs, affecting fertility.
Polycystic Ovary Syndrome (PCOS): PCOS is a hormonal disorder characterized by irregular ovulation and the presence of multiple small cysts on the ovaries. It can lead to subfertility due to irregular menstrual cycles.
Hormonal Imbalances: Imbalances in hormones such as follicle-stimulating hormone (FSH), luteinizing hormone (LH), and thyroid hormones can affect ovarian function and menstrual regularity.
Luteal Phase Defect: A shortened or inadequate luteal phase, the second half of the menstrual cycle, can impact the implantation of the fertilized egg.
Unexplained Infertility: In some cases, despite thorough evaluation, the cause of subfertility remains unexplained. This is known as unexplained infertility and may require a personalized approach to treatment.
Weight and Body Mass Index (BMI): Both underweight and overweight conditions can impact fertility. Extreme changes in weight, such as excessive exercise or drastic weight loss, can disrupt menstrual cycles.
Psychological Factors: Stress, anxiety, and other psychological factors can influence reproductive health and may contribute to subfertility.

Management of female subfertility involves a comprehensive assessment by a healthcare professional, typically a reproductive endocrinologist or gynecologist. Treatment options may include lifestyle modifications, hormonal therapies, assisted reproductive technologies (ART) such as in vitro fertilization (IVF), or surgical interventions, depending on the identified factors. Additionally, emotional support and counseling may be integral components of the overall management plan.

Subfertility Assessment

Assessment in the context of healthcare, particularly fertility and reproductive health, involves a systematic and comprehensive evaluation of various factors to understand an individual’s or a couple’s overall health and potential barriers to fertility. The assessment process encompasses both medical and personal aspects to provide a holistic understanding of the individual’s reproductive health. Here are key components of the assessment:

Medical History: Gathering detailed information about the individual’s medical history, including any pre-existing conditions, surgical history, medications, and past reproductive experiences.
Menstrual History: Understanding the regularity of menstrual cycles, any irregularities, and associated symptoms. This helps in assessing ovulatory function.
Sexual History: Exploring the frequency and timing of sexual intercourse, any difficulties or concerns, and the use of contraception methods.
Lifestyle Factors: Assessing lifestyle factors that may impact fertility, including diet, exercise, substance use, and exposure to environmental toxins.
Genetic and Family History: Examining the individual’s genetic background and any family history of reproductive or genetic conditions that could influence fertility.
Physical Examination: Conducting a physical examination to evaluate reproductive organs, identify any abnormalities, and assess overall health.
Hormonal Evaluation: Conducting hormonal tests to assess levels of reproductive hormones, such as follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, and thyroid hormones.
Ovulatory Assessment: Determining ovulatory function through methods such as basal body temperature charting, ovulation predictor kits, or monitoring hormonal changes.
Semen Analysis: For male partners, performing a semen analysis to evaluate sperm count, motility, and morphology.
Imaging Studies: Utilizing imaging studies, such as pelvic ultrasounds or hysterosalpingography, to assess the structure and condition of reproductive organs.
Diagnostic Procedures: Conducting diagnostic procedures like laparoscopy or hysteroscopy if further investigation of the reproductive organs is needed.
Psychosocial Assessment: Considering the psychological and emotional aspects of fertility, including stressors, coping mechanisms, and the impact of fertility challenges on mental health.
Counseling and Support: Providing counseling and support to address emotional well-being, coping strategies, and informed decision-making regarding fertility treatments. The assessment process is individualized, and the findings help healthcare professionals tailor a personalized treatment plan to address specific factors influencing fertility. The goal is to identify and address any barriers to conception while considering the physical, emotional, and social aspects of the individual or couple seeking fertility support.

The diagnosis

The diagnosis in the context of fertility and reproductive health involves the identification and determination of factors contributing to difficulties in conception or maintaining a pregnancy. A thorough diagnostic process is crucial to understanding the specific challenges an individual or couple may be facing. Here are key elements of the diagnostic phase:

Medical and Reproductive History: A detailed review of medical and reproductive histories helps identify any pre-existing conditions, past reproductive experiences, and potential risk factors.
Physical Examinations: Physical examinations, including pelvic exams for women and evaluations of reproductive organs, help identify any anatomical abnormalities or conditions that may affect fertility.
Hormonal Assessments: Hormonal tests, such as measuring levels of FSH, LH, estradiol, progesterone, and thyroid hormones, provide insights into the functioning of the endocrine system and reproductive hormones.
Ovulatory Assessment: Methods like basal body temperature charting, ovulation predictor kits, and hormonal monitoring assist in assessing ovulatory function. Among women, the most cost-effective fertility test involves monitoring and recording the Basal Body Temperature (BBT). The woman is directed to measure and record her BBT daily for a duration of four months. BBT is determined by taking the woman’s temperature before she rises in the morning and engages in any activities.
The daily temperature recordings should be accompanied by notes on any conditions that may influence the fluctuation of her temperature. During ovulation, there is a slight dip in temperature followed by a rise, though the increase should not exceed the normal temperature level. This elevated temperature persists for nearly 10 days, encompassing the 3 to 4 days preceding the onset of the next menstrual flow. If the observed temperature rise does not endure for the anticipated duration, a defect in the luteal phase is identified through this method.
Semen Analysis: For male partners, semen analysis evaluates sperm count, motility, and morphology to assess sperm health and function. Following a period of 2 to 4 days of sexual abstinence, the male is required to ejaculate via masturbation into a clean and dry specimen cup. The examination of the specimen takes a minimum of 1 hour, during which the sperm are counted.
The standard benchmark for a normal sperm count in each ejaculation is 20 million spermatozoa per milliliter of seminal fluid. To account for the continuous and cyclic process of spermatogenesis, the analysis is recommended to be repeated after a span of 2 to 3 months. Spermatogenesis is an ongoing process, and the newly produced sperm take approximately 30 to 90 days to reach maturity. Repeating the analysis after this period allows for an updated assessment of sperm quantity and quality.
Imaging Studies: Imaging studies, such as pelvic ultrasounds, hysterosalpingography, or sonohysterography, help visualize reproductive organs and identify structural abnormalities.
Genetic Testing: Genetic testing may be recommended to identify any hereditary conditions or genetic factors that could impact fertility.
Diagnostic Procedures: In some cases, diagnostic procedures like laparoscopy or hysteroscopy may be performed to directly visualize and assess the condition of reproductive organs.
Endometrial Biopsy: An endometrial biopsy may be conducted to evaluate the lining of the uterus for any abnormalities that could affect implantation.
Infectious Disease Screening: Screening for sexually transmitted infections and other infectious diseases is essential to identify and treat any underlying infections that may affect fertility.
Psychosocial Assessment: A psychosocial assessment may be included to understand the emotional well-being of individuals or couples, as psychological factors can impact fertility.

Tubal patency

Sonohysterography is a diagnostic imaging test utilized to assess the patency of the fallopian tubes, focusing specifically on the uterus. This ultrasound procedure involves filling the uterus with a sterile saline solution, followed by the insertion of a vaginal transducer to examine the uterine structure. The minimally invasive nature of this test allows it to be performed at any point during the menstrual cycle.

Another diagnostic test for evaluating the fallopian tubes is hysterosalpingography. This procedure involves the use of a radiopaque contrast medium to inspect the fallopian tubes. It is typically conducted post-menstruation to prevent the regurgitation of menstrual debris into the tubes.

It’s important to note that contraindications to hysterosalpingography include infections in the vagina, cervix, and uterus. These conditions may interfere with the procedure and compromise its accuracy.

Based on the findings from these diagnostic measures, healthcare professionals can establish a definitive diagnosis, identifying the specific factors contributing to fertility challenges. The diagnosis serves as the foundation for developing a targeted and personalized treatment plan to address the identified issues and enhance the chances of successful conception and pregnancy.

Subfertility Interventions

Implementation, in the context of fertility and reproductive health, refers to the practical application of strategies and interventions based on the findings from assessments and diagnoses. It involves executing the recommended treatment plan to address identified factors influencing fertility. Here are key aspects of implementation in fertility care:

Medical Treatments: Administering medical interventions such as hormonal therapies to regulate ovulation, manage hormonal imbalances, or address specific reproductive conditions. One therapeutic approach for addressing ovulation disturbances involves the administration of Gonadotropin-Releasing Hormone (GnRH). Additionally, Clomiphene citrate is employed to stimulate ovulation, while the administration of human menopausal gonadotropins is another method used to promote the growth of ovarian follicles.
Assisted Reproductive Technologies (ART): Implementing ART procedures like in vitro fertilization (IVF), intrauterine insemination (IUI), or other assisted methods to enhance the chances of conception.
Lifestyle Modifications: Guiding individuals or couples through lifestyle changes, including dietary adjustments, exercise routines, and stress management, to improve overall reproductive health.
Surgical Interventions: Conducting surgical procedures to address anatomical abnormalities, remove obstructions, or treat conditions impacting fertility. In contemporary practice, intrauterine insemination is widely employed as it holds a high likelihood of achieving a viable pregnancy. Surgical interventions are also utilized to address fertility challenges, including the removal of tumors that hinder fertility, such as myomectomy for the excision of myomas. Procedures like diathermy or steroid administration can be undertaken to correct tubal insufficiency resulting from inflammation. Additionally, laparoscopy or laser surgery may be considered for the removal of peritoneal adhesions or nodules.
Counseling and Support Services: Providing counseling services to address emotional aspects, alleviate stress, and support individuals or couples throughout the fertility journey.
Ovulation Induction: Implementing protocols to induce and regulate ovulation, especially in cases of ovulatory disorders.
Genetic Counseling: Offering genetic counseling services when hereditary factors are identified, providing information and guidance regarding potential genetic risks.
Monitoring and Follow-Up: Regularly monitoring the progress of interventions through follow-up appointments, hormonal assessments, and imaging studies to adjust the treatment plan as needed.
Educational Programs: Offering educational programs to empower individuals or couples with information about reproductive health, fertility awareness, and family planning.
Support Groups: Facilitating support groups to create a supportive community for individuals or couples experiencing fertility challenges, allowing them to share experiences and coping strategies.
Fertility Preservation: Implementing fertility preservation measures, such as egg or sperm freezing, for individuals facing medical treatments that may impact fertility.
Risk Reduction Strategies: Implementing strategies to reduce risks associated with fertility treatments, including multiple pregnancies and complications.
Continued Evaluation: Continuously evaluating the effectiveness of implemented interventions and making adjustments to the treatment plan based on ongoing assessments.

Therapeutic Insemination

Therapeutic Insemination, also known as Artificial Insemination, involves the deliberate introduction of sperm into the reproductive tract to facilitate conception. There are various methods of therapeutic insemination, each tailored to specific reproductive needs:

Intracervical Insemination: In this method, sperm is introduced into the cervix, optimizing the chances of fertilization.
Intrauterine Insemination: This technique involves the direct instillation of sperm into the uterus, providing a more targeted approach to conception.
Therapeutic Insemination by Husband: Utilizing the husband’s sperm, this method involves introducing the sperm into the reproductive tract of the wife, enhancing the likelihood of fertilization.
Therapeutic Donor Insemination: Using sperm from a donor, this approach involves introducing donor sperm into the woman’s reproductive tract to achieve conception.

Therapeutic insemination is commonly chosen by couples facing challenges related to low sperm count, sperm motility issues, or reproductive factors affecting fertility in women. Prior to the procedure, the woman typically determines her ovulation day through methods such as Basal Body Temperature (BBT) tracking, cervical mucus observations, or ovulation test kits.

Once the ovulation day is identified, the insemination is scheduled for the day after. During the procedure, sperm is introduced into the cervix using a specialized device resembling a cervical cap, or it may be instilled directly into the uterus. These methods aim to optimize the chances of sperm meeting the egg, increasing the likelihood of successful fertilization and conception.

Implementation in fertility care is a dynamic and personalized process, tailored to address the unique needs and challenges of each individual or couple. The goal is to optimize the chances of achieving a healthy conception and pregnancy while considering the physical, emotional, and social dimensions of fertility.

In Vitro Fertilization (IVF)

In the process of In Vitro Fertilization (IVF), one or more oocytes are retrieved from the woman and are fertilized by sperm in a laboratory setting, outside the woman’s body. This procedure is often chosen by individuals or couples facing challenges such as low sperm count in males or abnormalities in the fallopian tubes in females.

To prepare for IVF, the woman is administered an ovulation-stimulating agent. The development of ovarian follicles is closely monitored by daily ultrasound examinations, typically commencing on the 10th day of the menstrual cycle. Upon the maturation of a follicle, human chorionic gonadotropin (hCG) is injected, inducing ovulation within a window of 39 to 42 hours.

Following ovulation, the oocytes are aspirated, and then they are mixed and incubated with sperm. The first cell division occurs approximately 40 hours after fertilization, marking a critical stage in the early development of the embryo. The carefully orchestrated steps of IVF aim to optimize the chances of successful fertilization and subsequent implantation, increasing the likelihood of a successful pregnancy.