Sub-fertility: Causes and treatment

By Dr. Farouk Mahmoud

Married and sexually active, not resorting to any methods of family planning, the couple does not have a child. Could it be sub-fertility? Sub-fertility is when the wife -- even though the couple is not using contraception -- fails to get pregnant within 12 months. The incidence of sub-fertility in Sri Lanka is about 15%.

Normal conception

Usually, following sexual intercourse, the sperm from the husband travel from the vagina of the wife through the uterus (womb) into the fallopian tube. If an egg has been produced at that time in the wife, the sperm fertilizes the egg in the fallopian tube creating a tiny embryo (sperm-egg).

The embryo then tracks back into the uterine cavity, implants itself onto the endometrium (the lining of the womb) and grows into the foetus (the unborn baby). Therefore, eggs, sperm, fallopian tubes and endometrium are essential for conception.

The main causes of sub-fertility and what should be done to overcome them:

Ovulation (egg production) disorders

Ovulation is accomplished by a complicated and sophisticated feedback mechanism (Figure 1). As such, the lack of ovulation is mainly due to an inherent defect of the ovaries (polycystic ovaries -- PCO) or deficiencies of thyroid, adrenal or pituitary hormones.

The ovulation status can be detected by maintaining a temperature chart or carrying out a blood test or an ultrasound scan. The lack of ovulation can be overcome by surgical ablation of cysts in polycystic ovaries or medications (Clomiphene or follicular stimulating hormone) to produce one or many eggs.

Blockage of the fallopian tubes

A tubal obstruction in the wife may have occurred if there is a past history of operations or infection involving the uterus, ovaries or tubes or she has had appendicitis. The patency of the tube may then be assessed by an X’ray or a laparoscopic inspection after the injection of fluid through the tube.

Natural conception is possible if one of the two fallopian tubes is normal but if both are blocked surgery may be necessary to clear the block. Otherwise, the tubes could be bypassed as in procedures such as in-vitro fertilization.

Endometrial disorders (abnormal lining of the uterine cavity)

The implantation of the embryo may be hindered if the endometrium is damaged by adhesions (due to previous surgery) or the lining of the uterine cavity is distorted by fibroids. This can be detected by an ultrasound scan or a hysteroscopy (the inspection of the uterine cavity). If there are adhesions or fibroids which are affecting embryo implantation, they may have to be removed.

Male infertility due to lack of or faulty sperm

Sub-fertility in a couple (40-50%) may be due to male issues while the balance could be a combination of issues with the female. Male infertility could be due to sperms being low in number, motility or abnormal in form and shape. The major contributory factor for male infertility is testicular failure, the cause of which is unknown.

Figure 2 -Intra cytoplasmic sperm injection (ICSI)

Male infertility could be investigated by taking into account the husband’s past medical history whether he has got Mumps orchitis, mal-descended testes or undergone operations.

It is important to examine the size, consistency and mal-descent of testes and varicocele while also carrying out a semen analysis which is crucial to get a picture of the number, motility and abnormal shape of the sperms.

An ultrasound testis should be carried out only if there is a lump or cyst in the scrotum and a hormonal examination and biopsy testis will be necessary only if the semen count is abnormal
Apart from hormone treatment for those who need it and possibly correction of varicocele, in the majority of cases, sperm defects cannot be improved by treatment. The current approach is to select the best sperms and place it in the uterus (intra-uterine insemination - IUI), close to the egg (in-vitro fertilization -- IVF) or inject the sperm into the egg (intra-cytoplasmic sperm injection - ICSI).

Management of sub-fertility

There is treatment and thus hope for almost any type of sub-fertility. Early diagnosis and treatment are recommended, initially employing simple methods. The age of the wife is of importance and if she is older (over 35 years of age), the earlier the treatment, the better.

Where no cause has been determined for the couple’s sub-fertility, the chances of conception could be maximised by follicular monitoring by ultrasound (timing sexual intercourse to coincide with natural or medically induced ovulation) or IUI (if sperm is sub-optimal, the best available sperm being selected in the laboratory and placed in the uterus to enhance the progress of the sperm into the fallopian tubes for fertilization) or finally IVF.

IVF or IVF with ICSI should be used only when necessary and be performed by an infertility specialist at an approved facility.

In-vitro fertilization – IVF

Under this technique, the fallopian tubes are by-passed and many eggs produced with medication (aspirated under ultrasound control). The eggs are then fertilized using selected sperms in the laboratory. A few days later, two of the embryos thus produced are transferred into the uterus and the surplus embryos stored for future use.

Intra-cytoplasmic sperm injection- ICSI

This is a sophisticated technique where a single sperm is injected directly into the egg to facilitate fertilization (Figure 2). It is useful if the sperms are extremely poor in number and function.

Sperm-egg-embryo donation

Where the couple has no sperms, donated sperm could be used for IUI or IVF. If the wife has no eggs, donated eggs or embryos could be used for IVF.


If the wife has no uterus or pregnancy is contraindicated for medical reasons, another woman could nurture the pregnancy. The embryo (sperm from husband with egg from surrogate; both sperm and egg from donors or embryo from donor) could be used for surrogacy.

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