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Subfertility is defined as the absence of conception after a period of 12 months of normal unprotected sexual intercourse.
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Key facts and checkpoints
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Subfertility affects 10–15% of all cohabiting couples.
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The main factors to be assessed are ovulation, tubal patency and semen analysis.
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Approx. 40–50% of couples have an identifiable male factor.
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Female factors account for ∼45%: tubal problems account for ∼20% and ovulatory disorders ∼20%.
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Polycystic ovary syndrome is the most common cause of ovulatory dysfunction.
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Approx. 15% of cases have no apparent explanation.
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A significant number (25%) have combined male and female problems.
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Current specialised treatment helps 60% of subfertile couples to achieve pregnancy.
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A diagnostic approach
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It is important to see both partners, not just the woman.
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A careful history should include sexual function such as adequate intercourse, past history (esp. STI or PID), occupational history, drug intake and menstrual history.
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A general assessment of body habitus genitalia (inc. vaginal and pelvic examination), general health inc. diabetes mellitus, and secondary sexual characteristics should be noted in both man and woman. Urinalysis should be performed on both partners.
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Note: testicular size (measured with orchidometer)
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Essential first-line investigations
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The family doctor should perform the initial investigations of a couple with subfertility, inc. temperature chart, semen analysis and hormone levels, to determine whether it is a male or female problem and then organise the appropriate referral.
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It is advisable to obtain at least two or three samples at least 80–90 days apart. It requires a complete ejaculation, preferably by masturbation, after at least 3 days' sexual abstinence. Use a clean, dry, wide-mouthed bottle; condoms should not be used. Semen should be kept at body temperature and examined within 1 hour of collection.
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Educate about temperature chart and cervical mucus diary, noting time of intercourse (take temperature with thermometer under tongue before getting out of bed in the morning). Now considered of low value.
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Mid-luteal hormone assessment (21st d of cycle), i.e. serum progesterone (main first-line test for ovulation) and prolactin (refer Table I2).
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Treatable causes in female subfertility are tubular disease, anovulation and endometriosis: IVF guidelines re. NICE, UK.
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Treatable causes in males are rare.