Subfertility describes a delay in achieving conception after six months to a year of regular, unprotected intercourse. This differs from infertility, which implies an inability to conceive without medical intervention. With subfertility, natural conception remains possible, though it may take longer than average. This reduced chance of pregnancy often prompts couples to seek evaluation sooner to understand contributing factors.
Causes of Subfertility
Several factors can contribute to a delay in conception, affecting either partner or a combination of both. In females, ovulatory disorders are a common cause, where the ovaries do not release an egg regularly or at all. Polycystic Ovary Syndrome (PCOS) is a prominent example, characterized by hormonal imbalances, irregular periods, and excess androgen levels, which can hinder ovulation. Endometriosis is another female factor, occurring when uterine-like tissue grows outside the uterus, potentially causing inflammation, scar tissue, and structural issues that impair egg and sperm interaction or embryo implantation. A woman’s age also impacts fertility, as both the quality and quantity of eggs decline with advancing age, making conception more challenging after the mid-30s.
Male factors often involve issues with sperm production or function. Low sperm count, where sperm concentration is below normal levels, can reduce the likelihood of an egg being fertilized. Poor sperm motility, meaning sperm do not move efficiently or in a straight line, can prevent them from reaching and penetrating the egg. Varicocele, an enlargement of veins in the scrotum, can elevate scrotal temperature, negatively impacting sperm production and quality.
Shared and lifestyle factors also play a role in subfertility for both partners. Maintaining a healthy body weight is important, as being either overweight or underweight can disrupt hormonal balance and affect ovulation in women, and impact sperm quality in men. Smoking and heavy alcohol consumption negatively influence reproductive health; smoking accelerates ovarian aging in women and impairs sperm quality in men, while excessive alcohol intake can disrupt hormone production and reduce sperm production. Chronic psychological stress can also affect hormonal regulation and reproductive processes, potentially contributing to irregular menstrual cycles in women and reduced sperm quality in men.
The Diagnostic Journey
The diagnostic process for subfertility begins with an initial consultation, where healthcare providers gather a medical history from both partners. This includes details about menstrual cycles, previous surgeries, infections, or pregnancies for the female partner, and similar information for the male partner, alongside any current medications. This review helps identify potential underlying issues and guides the selection of appropriate diagnostic tests.
Following the history, a physical examination is performed for the female partner, including a transvaginal ultrasound to assess the uterus, ovaries, and surrounding pelvic structures. Female-specific tests include hormone blood tests to measure levels of Follicle-Stimulating Hormone (FSH), Estradiol (E2), and Anti-Müllerian Hormone (AMH), which provide insight into ovarian function and egg quantity. A Hysterosalpingogram (HSG) involves injecting a contrast dye into the uterus and fallopian tubes to visualize their patency and identify any blockages or structural abnormalities.
For the male partner, a semen analysis is an initial test, evaluating parameters such as semen volume, sperm count, sperm concentration, motility (movement), and morphology (shape). This analysis provides information about sperm health and its ability to fertilize an egg. If initial results are abnormal, a second semen analysis is recommended after several weeks to confirm findings, as sperm quality can fluctuate. In some instances, despite comprehensive testing, a specific cause for the delay in conception cannot be identified, leading to a diagnosis of unexplained subfertility, which accounts for about 15-30% of cases.
Medical Interventions for Subfertility
Medical interventions for subfertility aim to address identified causes, starting with fertility medications. Oral medications like Clomiphene citrate and Letrozole are prescribed to stimulate ovulation in women who experience irregular or absent ovulation. Clomiphene works by tricking the brain into releasing more follicle-stimulating hormone (FSH) and luteinizing hormone (LH), encouraging the ovaries to produce and release eggs. Letrozole, an aromatase inhibitor, lowers estrogen levels, similarly prompting the pituitary gland to increase FSH production, proving effective for women with polycystic ovary syndrome (PCOS).
Surgical options are considered for specific structural issues impacting fertility. For women, procedures can involve correcting uterine abnormalities, removing endometrial polyps, or excising certain types of fibroids that distort the uterine cavity or interfere with implantation. These surgeries are performed using minimally invasive techniques like hysteroscopy or laparoscopy. In men, surgical treatment for a varicocele, known as varicocelectomy, involves tying off enlarged veins in the scrotum to restore normal blood flow and improve sperm parameters.
When simpler methods are not successful, Assisted Reproductive Technology (ART) becomes a path. Intrauterine Insemination (IUI) is a less invasive ART procedure where a prepared sample of sperm is directly inserted into the woman’s uterus around the time of ovulation. This technique bypasses the cervix, shortening the sperm’s journey to the egg and increasing the number of sperm available for fertilization. In Vitro Fertilization (IVF) is an ART method where eggs are retrieved from the ovaries and fertilized with sperm in a laboratory setting. The resulting embryos are then monitored for growth before one or more are transferred into the woman’s uterus for implantation.
Lifestyle Approaches to Enhance Fertility
Alongside medical interventions, certain lifestyle adjustments can support fertility in both men and women. Adopting a balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats provides nutrients for reproductive health. Specific nutrients such as folic acid, zinc, selenium, and omega-3 fatty acids are important for egg maturation, sperm quality, and hormonal balance. Limiting processed foods, sugars, and trans fats is beneficial, as these can contribute to inflammation and insulin resistance, negatively impacting fertility.
Regular, moderate exercise is a step for improving fertility and overall well-being. Aiming for at least 150 minutes of moderate-intensity aerobic activity, such as brisk walking, swimming, or cycling, per week can help maintain a healthy weight and regulate hormones. For individuals with obesity, even modest weight loss through exercise can improve fertility outcomes. While moderate activity is beneficial, excessively strenuous exercise can have a counterproductive effect on hormonal balance and ovulation in women, or reduce sperm quality in men. Balance is important.
Managing stress effectively is another lifestyle approach. Techniques such as mindfulness, deep breathing exercises, and yoga can help reduce stress, which can affect hormonal regulation and reproductive processes. Engaging in hobbies, maintaining a strong social support network, and seeking professional counseling if stress becomes overwhelming can contribute to a positive mindset during the conception journey.
Understanding and timing intercourse with ovulation can enhance the chances of conception. The fertile window, a six-day period ending on the day of ovulation, is the period with the highest probability for pregnancy. Methods like tracking menstrual cycle length, monitoring changes in cervical mucus, or using ovulation predictor kits can help pinpoint this window. Having intercourse every one to two days during this fertile period ensures a consistent supply of viable sperm available for fertilization, optimizing conception.