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• Subfertility is defined as the failure to achieve pregnancy after one year of unprotected intercourse.
  • Primary subfertility indicates no previous conceptions.
  • Secondary subfertility refers to the inability to conceive after a previous viable pregnancy.
• Sterility is the inability to conceive due to a known condition, like the absence of a uterus.
• Subfertility in couples is attributed to:
  • 40% multifactorial issues
  • 30% male subfertility
  • 20-25% ovulatory failure in women
  • 20% tubal, vaginal, cervical, or uterine issues
  • 10% unexplained subfertility after available diagnostic tests
• On average when engaging in intercourse four times per week 50% of couples conceive within 6 months and 85% within 12 months.
  • Couples who engage in coitus daily may face greater difficulty in conceiving because it can lower a man's sperm count

Male Subfertility Factors

• Common factors that contribute to male subfertility:
  • Disturbance in spermatogenesis
  • Obstruction preventing sperm movement
  • Seminal fluid changes affecting sperm motility
  • Autoimmunity that immobilizes sperm
  • Problems in ejaculation preventing proper sperm deposition
• A normal sperm count is considered to be a minimum of 20 million/ml of seminal fluid, or 50 million per ejaculation.
  • 50% should be motile
  • 30% should be normal
  • Spermatozoa should be produced and maintained at slightly below body temperature.
• Conditions that significantly increase body temperature, like chronic infections or recurrent sinusitis, can lower sperm count.
• Actions that increase scrotal heat, such as desk jobs or frequent sauna use, may reduce sperm count.
• Congenital abnormalities like cryptorchidism can lower sperm production if not surgically repaired before puberty.
• Conditions that inhibit sperm production can include:
  • Trauma
  • Testicular surgery resulting in impaired circulation
  • Endocrine imbalances
  • Drug use
  • Environmental factors like radiation exposure
• For men with low sperm counts, abstinence from coitus for 7-10 days may help increase the count.

Ejaculation Problems

• Psychological issues, diseases like diabetes or Parkinson's, and certain medications can lead to erectile dysfunction, impacting the ability to achieve erection and ejaculation.
• Erectile dysfunction can be challenging to resolve if stress-related
  • Psychological or sexual counseling and drugs like Sildenafil can help
• Premature ejaculation can interfere with proper sperm deposition and is often linked to psychological causes.

Obstruction or Impaired Sperm Motility

• Obstruction can occur at any point in the pathway sperm travel to the outside:
  • Seminiferous tubules
  • Epididymis
  • Vas deferens
  • Ejaculatory duct
  • Urethra
• Mumps, orchitis, epididymitis, and gonorrhea can cause obstructions due to adhesion formation that occludes sperm transport.
• Anomalies of the penis, such as hypospadias or epispadias, can hinder optimal sperm deposition near the cervix.
• If sperm are immotile due to vas deferens obstruction, the obstruction is likely extensive and hard to relieve by surgery
  • Sperm extraction by syringe from a point proximal to the blockage can be used for intrauterine insemination.
• Sperm immobilization by vaginal secretions due to immunologic factors can be reduced by:
  • Abstinence
  • Condom use for about 6 months
  • Sperm washing and intrauterine insemination being alternatives.
• Corticosteroid administration to women may reduce sperm immobilization by reducing immune response and antibody production.

Female Subfertility Factors

• Factors causing subfertility in women are similar to those in men:
  • Anovulation
  • Problems in ova transport
  • Uterine factors
  • Cervical and vaginal factors that immobilize spermatozoa
  • Nutrition
  • Body weight
  • Exercise
• Anovulation is the most common cause of subfertility, potentially from genetic abnormalities like Turner's syndrome.
  • Ovarian tumors
  • Exposure to radiation
  • General ill health
  • Poor diet

Endometriosis

• Endometriosis is the abnormal growth of extrauterine endometrial cells, often in the cul-de-sac, peritoneal cavity, uterine ligaments, or the ovaries.
• Dysmenorrhea occurs as the abnormal tissue responds to estrogen and progesterone stimulation in the same manner as the uterine lining.
• Subfertility results if the fallopian tubes are immobilized and blocked by tissue implants or adhesions, preventing peristaltic motion and ova transport.
• Medical or surgical treatment can depend on the extent of the condition.
  • Estrogen/progesterone-based oral contraceptives
  • Danazol (Danocrine)
  • Administration of a GnRH agonist, such as leuprolide acetate (Lupron)
  • Laparotomy with excision by laser surgery

Pelvic Inflammatory Disease (PID)

• PID is the infection of the of the pelvic organs, the uterus, fallopian tubes, ovaries, and their supporting structures.
  • Although 75% is from sexual transmission, gonorrheal and chlamydial organisms being responsible infections from other causes such as E. coli or Streptococcus are also beginning to occur.
• PID begins with a cervical infection that spreads by surface invasion along the uterine endometrium and then out to the fallopian tubes and ovaries. Diagnosis is aided by ultrasound or laparoscopy.
• Therapy includes analgesia and broad-spectrum antibiotics such as:
  • Cefoxitin (Mefoxin)
  • Doxycycline (Vibramycin)
  • Clindamycin (Cleocin)

Diagnostic Examinations

• A minimum health history for subfertility in men should include:
  • General health
  • Nutrition
  • Alcohol, drug, or tobacco use
  • Congenital health problems
  • Illnesses
  • Radiation to his testes
  • Surgical repair of a hernia Operations
  • Current illnesses/Endocrine illnesses/low-grade infections
  • Occupation/work habits
  • Sexual practices: frequency of coitus and masturbation,
  • Contraceptive measures
  • Children from previous relationships Complementary therapy: herbal additives
    • Thorough history for women, asking:
      • Reproductive tract problems
      • Endocrine problems: galactorrhea (breast nipple secretions; and/or symptoms of thyroid dysfunction
      • History of Operations that could have compromised blood flow to pelvic organs
      • childhood cancer with radiation
      • Use of douches or intravaginal medications or sprays that could interfere with vaginal pH or toxic substances
      • Menstrual history:
        • Menarche age
        • Length/ regularity,
        • Problems with PDD
        • Contraception

Semen Analysis

• After 2-4 days of sexual abstinence ejaculation using masturbation for semen analysis.
  • Sperm count and examined within 1 hour
  • Sperm morphology, motility, and other characteristics that may indicate potential fertility issues.

Sperm Penetration Assay and Anti-sperm Antibody Testing

• Although sperm penetration studies are rarely necessary, they may be scheduled to determine whether a man's sperm, once they reach an ovum, can penetrate it effectively.
• IVF can injected sperm in order to bypass the need for sperm to fully motile

Ovulation Monitoring

• BBT is the least costly way to determine a woman's ovulation pattern.
• Women dip a test strip into a midmorning urine specimen and then compare it with the kit instructions for a color change.
• Sonohysterography inspects the uterus.
• Hysterosalphingography is a radiologic examination of the fallopian tubes using a radiopaque medium.
• Uterine Endometrial biopsies reveal an endometrial problem.

Assisted Reproductive Technique

• Therapeutic Insemination is sperm which is installed into cervix (intracervical insemination) or uterus( intrauteurine insemination).
• In Vitro Fertilization (IVF) is removing oocytes, fertilize in lab, fertilization, grown in lab, then inserted to uterus, It is most often used for couples who have not been able to conceive because a woman has blocked or damaged fallopian tubes
• Gamete Intrafallopian Transfer: Procedure for transferring eggs mixed with sperm into the fallopian tubes.
• Zygote Intrafallopian Transfer: Transfer of eggs that have been fertilized in vitro into the fallopian tubes.
• Surrogate Embryo Transfer: This is an assisted reproductive technique for a woman who does not ovulate, the donor's ovum being removed by a transvaginal, ultrasound-guided procedure.

Alternatives to Childbirth

• Surrogate Mothers: a woman who will be carrying a child as a surrogate
• Agency/private etc
• Child-Free Living: An alternative to surrogacy or adoption.

Miscellaneous

• A rectocele may develop if the rectum pouches into the vaginal wall.
• Adoption should be considered for couples who are infertile.
• Agency Adoption: Contacting an agency regarding adoption
• International Adoption.adopting from another country
• Private Adoption:adopting through a private adoption.

Terminologies

• Anovulation: faulty or inadequate release of ova
• Cryptorchidism: failure of one or both testes to descend from the abdominal cavity to the scrotum
• Endometriosis: abnormal growth of extrauterine endometrial cell
• Pelvic Inflammatory Disease (PID):Pelvic inflammatory disease
• Sperm motility: whether sperm seen to be activity