Misconceptions - Understanding fertility and the couple

March 01, 2011

What are the chances of natural conception in any couple?
Conception is most likely to occur in the first month of trying with a 30% conception rate. The chance of spontaneous conception or natural conception over the first 6 months of regular unprotected intercourse is approximately 75% and this rises to 90% after 1 year and 95% after 2 years of trying to conceive. In other words, at the end of 1 year, over 90 % of couples will have conceived provided both partners are normal and have no obvious reproductive problems.

What is ’subfertility’?
“Subfertility is the inability to conceive after 1 year of regular unprotected intercourse. The current recommendation to improve the chances of conception in any couple is a frequency of sexual intercourse of at least 3 to 4 times a week.

In order for a normal pregnancy to occur, an egg must be produced from the female ovary, adequate sperm must be released from the male testes, the sperm must reach the egg, fertilisation must occur and the fertilised egg must implant in the womb. If there is a problem in any of these steps, subfertility occurs.

How common is subfertility?
Fertility problems in a couple are increasingly becoming more common nowadays. It affects every 1 in 6 to couples or 15% of couples worldwide and the prevalence in increasing globally.

What factors affect the chances of successful conception?
The chances of spontaneous conception is affected by a number of factors including the age of the female partner, previous pregnancy history, duration of subfertility, frequency of sexual intercourse, timing of intercourse during the natural cycle, body mass index or weight, smoking and if there is any reproductive problem present. The single most important factor in determining fertility is the age of the female partner, with fertility reducing rapidly in women over the age of 35 years of age.

Generally speaking, a third of fertility problems occur in the female partner, a third of problems occur in the male partner and remaining third occur in the both partners.

Problems contributing to subfertility can be broadly grouped into:
  • Ovulation problems (30%)[defective release of egg]including Polycystic Ovarian Syndrome,
  • Male problems (25%)[defective sperm],
  • Tubal problems (25%) [sperm cannot meet egg],
  • Unexplained (25%),
  • Implantation problems (30%),
  • Endometriosis,
  • Fibroids,
  • Cervical and coital problems (<5%).
In 30-40% of couples, a problem will be found in both partners.

When to investigate for subfertility?
Fertility investigations are usually commenced after 1 year of regular unprotected intercourse but it is advisable to start investigations earlier if selected cases, such as, in women more than 35 years or those with known gynaecological pathology.

What are the recommended investigations for subfertility?
Initial investigations should be completed within a few months and these should establish if the woman is ovulating or not, if semen quality is good or not and if the patency of the fallopian tubes are normal or not. Both partners must be investigated in parallel as both male and female factors can occur concurrently.

Initial investigations should establish the following points.
  1. Does the woman ovulate?
  2. If not, then why not?
  3. Is there tubal damage(damage to fallopian tubes) or uterine abnormality(abnormality in the womb)
  4. Is the semen quality normal?

How to test for ovulation problems?
The recommended test is the measurement of gonadotrophins (FSH and LH) in the blood in the first half of the menstrual cycle and the hormone progesterone in the blood in the second half of the menstrual cycle in a woman with regular cycles, commonly known as the mid-luteal progesterone level. The progesterone test is usually done on day 21 of the cycle in a woman with a 28 day cycle or 7 days before expected menses.

Alternatively, serial ultrasound scan measurements of ovarian follicles can be performed to measure follicular growth and confirm ovulation.

In women with irregular cycles, additional hormone tests are required to look for any endocrine abnormality such as polycystic ovarian syndrome (PCOS), raised prolactin or thyroid problems.

How to test for tubal problems?
Tests of fallopian tubal patency all rely on visualisation of solutions passing through the tubes into the abdominal cavity. The two commonly done test to determine tubal patency are the Laparoscopy and Dye test and Hysterosalphingography (HSG)

The ‘Lap and Dye’ test as it is commonly referred to involves a laparoscopy or a minor key hole surgical procedure and needs a general anaesthesia. Tubal patency is then tested by instilling a dye through the cervix and observing the spillage of dye from the tubes. It allows a thorough assessment of the pelvis and tubal patency and enables treatment of any abnormality, such as endometriosis or adhesions, to be carried out at the same time.

HSG, on the other hand, is an outpatient radiological procedure that involves injecting contrast media into the uterine cavity and using x- ray imaging to follow the flow of contrast into the tubes and detect spillage into the abdominal cavity. There is no spillage into the abdominal cavity when there is tubal blockage.

How do we test for semen quality?
The investigations in the male partner are relatively simple and straightforward and consists of producing a semen sample for analysis in the laboratory for measurement of semen quality specifically measuring parameters such as sperm concentration (quantity), motility (movement) and morphology(shape).

However, it is important that the semen analysis is performed under proper conditions i.e the semen sample should ideally be produced by masturbation after 3 to days of sexual abstinence.

How can fertility problems affect a couple’s general wellbeing?
Subfertility can be a very stressful life event. Couples usually present to a fertility specialist because they have not conceived as quickly as they had expected. Some are concerned that they have a serious problem that will stop them from having a family. Many couples find it stressful to seek professional help for such an intimate problem and feel a sense of failure at having to do so. The whole experience can be very stressful for the couple and can even lead to a breakdown in sexual relationship or marriage and occasionally depression. Professional counselling by trained personnel is necessary to alleviate anxiety and reduce stress and to provide reassurance that there are successful treatments available.

Dr. Sharad Ratna
General Obstetrician and Gynaecologist
Visiting Consultant Columbia Asia Hospitals