Subfertility in Women
Subfertility is defined as the failure to conceive after 12 months of regular, unprotected intercourse (6 months if the woman is >35). Early, systematic assessment helps identify reversible causes and appropriate referral. Assessment should include history, examination, ovulation assessment, semen analysis and investigations of tubal/uterine pathology.
NICE NG88: Heavy Menstrual Bleeding (context for investigation of structural causes),
NHS fertility pathway supports early referral based on age and risk factors.
🌸 Initial Assessment – History
- ⏳ Duration: No conception after 12 months (or 6 months if ≥35 yrs).
- ❤️ Sexual History: Frequency/timing, dyspareunia, erectile dysfunction, condom use.
- 🧷 Contraception History: Duration and time since stopping.
- 🤰 Pregnancy History: Previous conceptions, miscarriages, ectopics.
- 🩸 Menstrual History: Cycle length, regularity, ovulatory symptoms, amenorrhoea/dysmenorrhoea.
- 🩺 Medical History: PCOS, thyroid disease, diabetes, endometriosis, PID, pelvic surgery.
- 👪 Family History: Early menopause, genetic conditions, recurrent miscarriage.
- 🍷 Lifestyle Factors: Smoking, alcohol, BMI extremes, recreational drugs, stress.
🔎 Physical Examination
- 📏 General: BMI, acne/hirsutism (androgen excess).
- 🩻 Pelvic Exam: Uterine size/contours, adnexal masses, tenderness.
- 🦋 Thyroid Exam: Goitre/nodules that may affect cycles.
🧪 Initial Investigations
- 🩸 Ovulation Testing: Day‑21 progesterone indicating recent ovulation.
- 🦋 Thyroid Function: TSH/FT4 to rule out thyroid dysfunction.
- 🍼 Prolactin: Hyperprolactinaemia can suppress ovulation.
- 🥚 Ovarian Reserve Tests: AMH, antral follicle count (US).
- 🖥️ Pelvic Ultrasound: Detects PCOS, fibroids, endometriomas.
- 🧪 Semen Analysis: Essential for male partner (EKG NICE/UK fertility pathways).
- 🩻 Hysterosalpingography (HSG): Uterine cavity and tubal patency.
🔬 Further Specialist Investigations
- 📹 Laparoscopy: Gold standard for endometriosis/adhesions.
- 🔎 Hysteroscopy: Visualises and treats intrauterine anomalies (polyps/septum).
💊 Management Approaches
- 🌿 Lifestyle: Weight optimisation, smoking/alcohol cessation, stress management.
- 📅 Timed Intercourse: During fertile window (mid‑cycle ovulation).
- 💊 Ovulation Induction: Letrozole (first line in PCOS), clomiphene citrate, or gonadotropins as appropriate.
- 🔧 Surgery: Myomectomy (fibroids), excision of endometriosis, tubal surgery in selected cases.
- 🧬 Assisted Reproduction (ART):
- 🤱 IUI: Washed sperm introduced into uterus (mild male factor/unexplained).
- 👶 IVF: In vitro fertilisation for many causes including tubal factor/failed treatments.
- 💉 ICSI: Single sperm injection for severe male factor.
🧠 Psychological & Emotional Support
- 🗣️ Counselling: For stress, anxiety, relationship impact of subfertility.
- 🤝 Support Groups: Peer support and coping strategies.
📩 Referral Criteria
- Refer to fertility specialist if no pregnancy after first‑line management.
- Refer earlier if woman is ≥35, irregular cycles, amenorrhoea, significant male factor, known tubal disease or severe symptoms.
⚠️ Major Causes of Subfertility in Women
- 🌀 Ovulatory Disorders:
- PCOS, anovulation detected via irregular cycles, hormonal tests and US.
- Treatment: weight loss, ovulation induction (letrozole/clomiphene), IVF if needed.
- 🌹 Endometriosis:
- Symptoms: dysmenorrhoea, dyspareunia, chronic pelvic pain; US/diagnostic laparoscopy.
- Treatment: laparoscopic excision, hormonal suppression, ART for advanced disease.
- 🚧 Tubal Factor:
- HSG/laparoscopy shows blocked/damaged tubes.
- Treatment: tubal surgery in select cases; IVF often preferred.
- 🏛️ Uterine Factors:
- Fibroids, polyps, septa → detected by US/hysteroscopy.
- Treatment: myomectomy, hysteroscopic resection; IVF if persistent.
- ⏳ Premature Ovarian Insufficiency:
- Elevated FSH, low estradiol/AMH, possible karyotype if <40 yrs.
- Treatment: HRT for health; pregnancy with donor eggs + ART.
💡 Exam Tip: Always assess both partners in infertility. Structure OSCE answers as: 🧩 History → 🔎 Exam → 🧪 Investigations → 💊 Management → 🧠 Psychosocial support → 📩 Referral.
📚 NICE & UK Fertility Resources
