Definition and Background
Subfertility is a reduced capacity to conceive. It can lead to considerable psychological distress in those affected. Subfertility is relatively common and seen frequently by the GP – 1 in 6 UK couples are affected. Some 30% of couples will conceive after 1 month of trying; 60% of couples after 6 months; 84% after 12 months and 92% after 24 months. So, in the first 12 months of trying to conceive, simple advice is usually enough. Beyond 12 months, or if there is any special cause for concern, the GP needs to be proactive with investigations, support and understanding.
Aetiology
Female fertility is known to decline with age, especially after 35 years. However, subfertility can commonly be caused by problems in either partner: up to half by female disorders; about one-third by male disorders; about 10% by both partners; and in 10% the cause will remain unexplained.
History
Ideally, you should see both partners. Your history should include the following:
- Lifestyle issues for both partners, especially smoking and alcohol (see management section, below).
- Contraception (fertility can take a while to return after some contraceptive methods – up to 12 months following the Depo injection, for example).
- Ask about the woman’s normal menstrual cycle and age, history of undescended testes or varicocele in the man, chronic infection such as HIV, hepatitis B or C and any previous cancer treatment in either partner.
- Previous pregnancies involving either partner (is this primary or secondary infertility?).
- History of sexually transmitted infection.
- Ask both partners about their occupation (do they involve hazards that can affect male or female fertility).
- Full medical, surgical and drug history. Systemic disease such as thyroid, diabetes or inflammatory bowel disease can have an adverse effect on fertility, as can their treatments; pelvic, abdominal or genital surgery is also relevant.
Examination
- Calculate both partners’ body mass index (BMI), particularly relevant for the woman (see Figure 23a).
- Look for signs of polycystic ovaries in the woman: acne, hirsutism, male pattern baldness. Examine the breasts if there is a history of galactorrhoea and perform an abdominal, speculum and pelvic examination – look also for signs of undisclosed sexual difficulties such as vaginismus.
- Examine the man for gynaecomastia and also examine his external genitalia – observe the appearance of the penis, the testicular location, size and consistency, any sign of varicocele or inguinal hernia.
Investigations
Start investigations for couples who have not conceived after 1 year of regular unprotected intercourse or before if you suspect a problem (e.g. a woman >35 years or with irregular periods, history of pelvic infection or surgery, or male history of undescended testis). In primary care, blood tests can be arranged for the woman to check her ovulation and semen tests organised for the man.
Management
Couples should be seen together wherever possible. Remember that this can be a very stressful time for both of them. They will need support and assurance that something is being done – even though many will go on to conceive without any intervention. Remember that there may be feelings of guilt (e.g. about previous terminations or delaying start of family) or inadequacy (particularly in some cultures, where pressure to have children is high) that may need exploring for both partners.
GPs should make all couples aware of lifestyle changes to improve their chances of conception. Some of these questions are very personal, but explaining why they are relevant can help put the couple at ease:
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