Couples should seek medical advice if they have not been using contraceptives for a year or longer without achieving a pregnancy. Where the female partner is older than 35 years or there is a known cause of sub-fertility, this advice should be sought after 6 months.
Causes of delayed conception may be due to male, female or a combination of both factors. Often, no specific reason is found in about 1 in 3 couples. Female related causes are categorized into lack of ovulation or blocked Fallopian tubes.
Ovulation is predictable by the menstrual pattern. Regular menstrual periods is an accurate indicator that ovulation happens, whereas irregular periods indicate unpredictable or a lack of ovulation.
Fallopian tubes are essential for fertilisation and transport of the fertilised egg to the womb. Damage resulting from infection, inflammation or surgery can block the fallopian tubes.
Male factor sub-fertility is diagnosed by examining a semen sample which may reveal a low sperm count or no sperm on the ejaculate. When sperm is not seen, this may be due to a failure of sperm production or blockage in the tubes connecting to the testes. Complementary hormone profile offers further insight in making this distinction.
Treatment options vary depending on duration of sub-fertility and/ or the identified cause.
Where no cause is identified also known as unexplained sub-fertility and the female partner is younger than 38 years, the cumulative chance of conceiving within two years is about 90% if the couple continue trying. This is also the case for a slight reduction in sperm concentration
Ovulation induction is recommended for women with irregular periods commonly due to poly cystic ovarian syndrome.
When the fallopian tubes are blocked or severely low sperm concentration, assisted reproductive treatment (ART) is recommended as this will give the best chance to achieving a pregnancy.
For men with azoospermia (no sperm seen), retrieval of testicular sperm for use in assisted reproductive treatment achieves similar pregnancy outcomes to other causes of subfertility.
Couples with unexplained subfertility and have tried longer than 2 years have the best chance in achieving a pregnancy with use of assisted reproductive treatment. This is due to the low cumulative pregnancy rate (less than 5%) beyond two years of trying.
Only in a few couples will use of intrauterine insemination be an option to achieving a pregnancy. This include treatment involving use of donor sperm and where there is a medical or other reason that prevent regular intercourse.
The fallopian tubes are attached to the womb on one end and open next to the ovary in a trumpet like fashion on the other end. Functionally, fallopian tubes pick up an ovum (female egg) and facilitate fertilisation and transport the fertilised egg (embryo) to the womb for implantation and establishment of a pregnancy. Blockage or damage to the inner lining of the fallopian tubes will compromise ovum pick-up, fertilisation and transport of a fertilised egg. This result in difficulty in conceiving. Sometimes, this damage predisposes to an ectopic pregnancy. Damage and blockage to the fallopian tubes occurs in nearly 1 in 3 women experiencing difficult conceiving. The damage may be due to infection (such as chlamydia or appendicitis), scarring (from endometriosis or pelvic surgery such as fibroid removal [myomectomy]) or female sterilisation (tubal ligation).
A definite diagnosis of tubal damage is made using laparoscopic surgery as it allows direct visualisation and offers the opportunity for treatment. However, as this requires general anaesthesia and theatre set-up, less invasive tests are preferable to laparoscopy. HyCoSy, also known as hysterosalpingo-contrast sonography is a simple and straight forward procedure to check patency of fallopian tubes.
It involves performing an ultrasound scan to look at the uterus and ovaries while injecting a special dye in a catheter (tube) through the cervix. The procedure takes about 20 minutes by a specially trained practitioner. HyCoSy has the advantage of giving real-time information about the ovaries and womb in addition to tubal patency. This is cost-effective and has good satisfaction rates. Where HyCoSy is not available, traditional HSG (hysterosalpingography) is performed. It involves injecting a special dye through the cervix and taking x-ray images that show the uterine cavity and fallopian tubes. Hysterosalpingogram has the disadvantage of not giving information about the ovaries and the whole uterus. This means that additionally, an ultrasound scan examination is required.