Subfertility is defined as not getting pregnant within a year of having regular sex without using contraception. Not all couples get pregnant straight away when they start trying. Over 80% of couples in the general population will conceive within 1 year if the woman is aged under 40 years, they do not use contraception and have regular sexual intercourse. Of those who do not conceive in the first year, about half will do so in the second year.

There are two types of female subfertility.

Primary subfertility. This means you have never been pregnant.

Secondary subfertility. This is when you have been pregnant before but are now having difficulty.

What are the causes of subfertility?

There are various reasons why you may have trouble getting pregnant, although in about a third of couples, we can’t find any cause. The causes could be male factor or female factor related or both.

Factors affecting both male and female fertility are:

Being overweight – having a body mass index (BMI) of 30 or more

Being underweight – having a BMI of less than 19

Smoking – this includes passive smoking too

Drinking alcohol – don’t drink more than one to two units of alcohol once or twice a week if you’re trying to get pregnant

Using illegal drugs, such as marijuana or cocaine

Taking certain medicines, including non-steroidal anti-inflammatory drugs (NSAIDs), antipsychotics to treat conditions such as schizophrenia and spironolactone.

Stress – this can affect your relationship and desire to have sex

The most common reasons for subfertility in women are:

Your ovaries not producing eggs

Blocked tubes

Subfertility can also be caused by problems with your womb or cervix (neck of your womb). One example is fibroids (non-cancerous growths in your womb), especially if they have grown into its lining and polyps in the lining of the womb.

Male factor subfertility

Abnormal semen analysis due to various factors.

This can be tested easily by doing a semen test. If the initial test is abnormal, it should be repeated.

Do I need tests?

If you have been trying to get pregnant for a year and are worried about your fertility, see your GP.

You will need full assessment and baseline investigations. Tests include blood tests to check if you’re ovulating and to look at your hormone levels and infection screen. Investigations include an ultrasound scan to check your fallopian tubes, ovaries and uterus.

Further tests at a hospital or fertility clinic may include the following.

Tubal Patency tests: A hysterosalpingography (HSG) or saline infusion sonography (HyCoSy) to check for the patency of the fallopian tubes. In HSG, a dye is passed through the tubes and X rays are taken to check if the dye comes out through the tubes or not. In HyCoSy, we use ultrasound to check whether your fallopian tubes are open or not.

Laparoscopy and dye test:  In some situations (history of pelvic infections, previous ectopic pregnancy, endometriosis), you may have laparoscopy and dye test to check for the patency of the tubes and to look for the above conditions.

What are the options?

Lifestyle modifications: Some changes to your lifestyle will improve the chances of conception. These may include stopping smoking, not drinking more than one to two units of alcohol once or twice a week and optimising your BMI (body mass index).

Medical and Surgical options: If your subfertility is caused by an underlying health condition, getting treatment for this may improve your chance of becoming pregnant.

Types of fertility interventions available include:

Medical treatment for lack of regular ovulation

Surgical procedures – such as treatment for endometriosis

Assisted conception – which may be intrauterine insemination or IVF

Medicines: If your infertility is a result of a problem with ovulation, you may be prescribed a medicine to stimulate your ovaries to produce eggs. One example is Clomiphene Citrate. You will be monitored closely as there is a risk of producing more than one egg, which could lead to a multiple pregnancy.

Surgery: Surgery may be an option if you have endometriosis, adhesions or scarring, fibroids or tubal factors. Laparoscopic surgery is feasible in most of the cases. If endometrial polyps or fibroids are found in the lining of the womb, these can be easily removed using hysteroscopy.

Assisted reproduction: There are several methods used for assisted conception. The ones that are best for you will depend on what is causing your infertility.

The main methods are:

Intra-uterine insemination (IUI) – sperm (from your partner or a donor) are placed into your womb around your time of ovulation

In vitro fertilisation (IVF) – an egg (taken from you or a donor) is fertilised with sperm in a laboratory and transferred into your womb

Intracytoplasmic sperm injection (ICSI) – one sperm is injected into one of your eggs in a laboratory and then transferred into your womb