Last updated date: 08-Jan-2023

    Originally Written in English




    Subfertility and infertility are frequently used interchangeably, however they are not the same thing. Subfertility is the inability to conceive. Infertility is defined as the inability to conceive naturally after a year of attempting. The chance of conceiving spontaneously exists with subfertility, although it takes longer than usual. The chances of conceiving without medical assistance are slim with infertility. According to studies, most couples may conceive spontaneously after 12 months of regular unprotected intercourse.


    What is Subfertility?


    Subfertility is described as the inability to conceive after a year of unprotected frequent sexual contact. Although it is normally fair to begin inquiries after this period, early investigations and referral may be warranted if either partner's past contains significant issues.

    One of the most important elements influencing a woman's chances of conception is her age. Most therapies' odds of effectiveness decrease dramatically once a woman reaches the age of 35, and they become zero by her mid-40s. As a result, in order for couples to reap the greatest benefit from the most appropriate treatment, investigations should be initiated as soon as possible (after six months of trying if the woman is over 35) and completed in accordance with a locally agreed protocol between general practitioners and hospital providers. Couples can then be counseled on the significance of the test results, and a management plan that takes into account the test results as well as the couple's values and wants can be agreed upon.

    At the initial presentation, both spouses should be interviewed and evaluated. Intercourse two to three times per week is recommended, although baseline body temperature charts are ineffective and should be avoided.


    What are the common signs and symptoms of subfertility?

    symptoms of subfertility

    There are several disorders that might lead to male and female subfertility. The indications and symptoms of each might be very different. If you are worried, you should talk with your doctor.

    The following are common signs of subfertility.

    Subfertility Symptoms in Women

    1. Inconsistent periods

    The average woman's cycle lasts 28 days. However, anything within a few days of that is normal, as long as the cycles are continuous. A woman who has a 33-day cycle one month, a 31-day cycle the next, and a 35-day cycle the following month is most likely experiencing "regular" periods. A woman with irregular periods has cycles that fluctuate so much that she can't even guess when her period will arrive. This might be due to hormonal imbalances or polycystic ovarian syndrome (PCOS). Both of these can lead to infertility.

    2. Periods that are painful or heavy

    Most women get cramps throughout their periods. However, painful periods that interfere with your everyday life might be a sign of endometriosis.

    3. There are no periods

    It's usual for women to have a bad month every now and again. Stress or strenuous exercise might cause your menstruation to vanish momentarily. However, if you haven't had a period in months, you should have your fertility evaluated.

    4. Hormone fluctuation symptoms

    Hormone variations in women may suggest probable reproductive concerns. Consult your doctor if you suffer any of the following symptoms:

    5. Discomfort during sex

    Some women have had painful sex their whole lives and have convinced themselves that it is normal. But it isn't. It might be due to hormonal imbalances, endometriosis, or other underlying disorders that are also contributing to infertility.

    The capacity of a guy to keep an erection is frequently tied to his hormone levels. Reduced hormone levels may follow, which might lead to difficulties conceiving.

    6. Ejaculation problems

    Similarly, failure to ejaculate indicates that it is time to see a doctor.

    7. Firm, small testicles

    Because the testes are where a man's sperm is stored, testicle health is critical to male fertility. Small or hard testicles may suggest possible problems that should be investigated by a medical professional.


    Common subfertility Symptoms in Men

    1. Variations in sexual desire

    The health of a man's hormones is also connected to his fertility. Changes in virility, which are frequently influenced by hormones, may suggest reproductive problems.

    1. Pain or swelling in the testicles

    There are several disorders that can cause discomfort or swelling in the testicles, many of which might contribute to infertility.

    1. Problems with erection maintenance

    The capacity of a guy to keep an erection is frequently tied to his hormone levels. Reduced hormone levels may follow, which might lead to difficulties conceiving.

    1. Ejaculation problems

    Similarly, failure to ejaculate indicates that it is time to see a doctor.

    1. Firm, small testicles

    Because the testes are where a man's sperm is stored, testicle health is critical to male fertility. Small or hard testicles may suggest possible problems that should be investigated by a medical professional.

    What causes subfertility?

    Causes subfertility

    The majority of the reasons of subfertility are the same as those of infertility. Male or female infertility, or a mix of the two, might cause difficulty conceiving. The reason is uncertain in some situations.

    The most prevalent reason for infertility is an ovulation issue. An egg is not released to be fertilized unless ovulation occurs.

    Ovulation can be prevented by a variety of situations, including:

    • PCOS is a condition that can either prevent or induce irregular ovulation.
    • DOR is a decline in a woman's egg count caused by age or other factors such as a medical condition or past ovarian surgery.
    • precocious ovarian insufficiency (POI) :Trusted Source, also known as premature menopause, when the ovaries die before the age of 40 as a result of a medical illness or treatment, such as chemotherapy.
    • Hypothalamus and pituitary gland disorders, which interfere with the capacity to generate the hormones required to maintain normal ovarian function


    • Obstruction of the fallopian tube

    The egg cannot meet the sperm because the fallopian tubes are blocked. It can be brought on by:

    • pelvic inflammatory illness caused by endometriosis (PID)
    • scar tissue from a prior operation, such as an ectopic pregnancy procedure
    • a gonorrhea or chlamydia history


    • Abnormalities in the uterus

    The uterus, often known as the womb, is where your baby develops. Abnormalities or defects in the uterus might make it difficult to conceive. This can include congenital uterine problems that are present at birth or a later-developing problem.

    Some uterine problems are as follows:

    • Septate uterus, characterized by a band of tissue dividing the uterus into two portions
    • The uterus contains two chambers instead of one, approximating the form of a heart. 
    • The uterus has two tiny cavities, each with its own opening. 
    • Fibroids are abnormal growths inside or on the uterus.


    • Sperm production or function issues

    Subfertility can be caused by abnormal sperm production or function. A variety of circumstances and causes can contribute to this, including:

    • Gonorrhea
    • Chlamydia
    • HIV
    • Diabetes
    • Mumps
    • Cancer, and cancer therapy 
    • Varicocele hereditary abnormalities, such as Klinefelter syndrome, cause swollen veins in the testes.


    • Complications with sperm delivery

    Problems with sperm delivery might make conception difficult. This can be caused by a variety of factors, including:

    • Genetic problems such as cystic fibrosis.
    • Premature ejaculation injury.
    • Testicular anatomical anomalies such as a testicle blockage.


    What are the risk factors of subfertility?

    risk factors of subfertility

    Certain factors enhance your chances of infertility. Many of the risk factors for male and female infertility are the same. These are some examples:

    • Being a female over the age of 35.
    • Being a male over the age of 40.
    • Being overweight or underweight.
    • Smoking cigarettes or marijuana.
    • Significant physical or mental stress.
    • Exposure to radiation.
    • Certain medicines.
    • Toxins in the environment, such as lead and pesticides.


    What are the techniques to investigate subfertility?

    Beginning investigation in primary care

    Primary care

    • Is the woman ovulating, and if not, why?

    Checking a mid-luteal phase progesterone level to confirm ovulation in a regular cycle is recommended by the UK Royal College of Obstetricians and Gynaecologists. Time the sample at the appropriate stage of the cycle (seven days before expected menses). Ovulation is improbable when periods are irregular or the woman has oligomenorrhea (a cycle length of more than 35 days) or polymenorrhea (a cycle length of less than 25 days), thus a progesterone test is ineffective. Thyroid stimulating hormone, testosterone, and prolactin levels should be examined only if cycles are irregular or missing, indicating anovulation, galactorrhoea, or thyroid disease symptoms. Transvaginal ultrasonography is a straightforward procedure for detecting polycystic ovaries and uterine fibroids. FSH, and estradiol levels should be measured early in the cycle (days 2 to 6).

    • Is the quality of sperm normal?

    A sperm analysis should be performed on the male partner, and if any parameters are abnormal, a second test should be performed six weeks later. The samples should ideally be tested at the laboratory of the reproductive clinic to whom the couple will be referred. As a typical part of the first examinations, further extensive sperm function testing is not required. The postcoital test is untrustworthy and should not be used as a normal examination.

    Primary care investigations should be conducted at a specialist reproductive medicine or fertility facility.


    Secondary care Investigations

    Secondary care investigations

    • Is there any tubal or uterine abnormality?

    Tubal status and uterine cavity examinations can be conducted on women.

    • Hysterosalpingography (HSG) 
    • Laparoscopy and dye test with hysteroscopy
    • Hysterosalpingo-contrast sonography (HyCoSy)

    Tubal patency tests should be performed during the first 10 days of a cycle to prevent disturbing an early spontaneous pregnancy, which is improbable. Prophylactic antibiotics such as doxycycline and metronidazole should be administered to reduce the risk of infection developing after the surgery unless cervical screening for chlamydia has been conducted.


    HSG and HyCoSy

    HSG and HyCoSy are "dynamic" outpatient procedures that include placing a catheter into the cervical canal and injecting contrast into the uterine cavity. HSG employs real-time x-ray imaging to track the passage of contrast through the tubes and into the peritoneal cavity, whereas HyCoSy employs ultrasonography. Both provide information about the uterine cavity's shape. Because an ultrasound scan of the pelvis is conducted at the same time, HyCoSy provides additional information, allowing the diagnosis of fibroids or polycystic ovaries.


    Dye test and laparoscopy

    A laparoscopic and dye test requires general anesthesia and carries the risks associated with laparoscopy. It does, however, provide information on the extent of any tubal damage present and allows endometriosis to be recognized. Furthermore, laparoscopic therapy such as diathermy or laser ablation of endometriosis, salpingolysis, or salpingostomy may be performed concurrently. HyCoSy and HSG can be used as a first screen, with laparoscopy reserved for individuals with a history or symptoms indicating a risk of tubal damage or endometriosis, as well as those with an abnormal HSG. If the male partner's sperm quality is so poor that assisted conception therapy (such as intracytoplasmic sperm injection) is expected, tubal evaluation may not be necessary. However, if ultrasonography reveals the existence of submucosal fibroids, information regarding the uterine cavity may be useful.


    Further research into azoospermia in secondary care

    A centrifuged sample should be checked for sperm in the pellet if the first semen assay indicates azoospermia. Even if just a few sperm are discovered, intracytoplasmic sperm injection can be used as a successful therapy to overcome infertility.

    If azoospermia is diagnosed, it is critical to differentiate between obstructive and non-obstructive azoospermia.

    Spermatogenesis is normal in obstructive azoospermia, however there is an obstruction in the epididymis or vas deferens. If vas deferens absence is suspected, both spouses should be screened for cystic fibrosis because many of these males will have one of the cystic fibrosis variants. Spermatogenesis is hampered in non-obstructive azoospermia.

    This impairment may be caused by testicular failure (in which case the man's karyotype should be evaluated, and numerous testicular biopsies may reveal localized foci of spermatogenesis) or by a failure of the hypothalamus pituitary axis to induce spermatogenesis (hypogonadotropic hypogonadism). Although uncommon, this illness should be suspected since these individuals react to gonadotrophin therapy. 


    How is subfertility diagnosed?

    Subfertility diagnosed

    A subfertility expert can assist in determining the reason for subfertility. A doctor will begin by gathering both parties' medical and sexual histories.

    The doctor will also do a physical examination, which will include a pelvic exam for women and a genital examination for males. A subfertility assessment will also entail a battery of tests.

     Women may be ordered the following tests:

    • Transvaginal ultrasonography examination of the reproductive organs
    • Blood tests to detect ovulation-related hormone levels
    • Hysterosalpingography to assess the state of the fallopian tubes
    • Uterine ovarian reserve testing to determine the quality and number of eggs

    Men's tests may include:

    • Blood tests to measure hormone levels in sperm, including testosterone
    • Imaging tests, such as a testicular ultrasound
    • Genetic test to look for genetic flaws that may influence fertility
    • Testicular biopsy for anomalies


    What are the subfertility treatment options?

    Subfertility treatment

    Being subfertile rather than infertile indicates that natural conception is still feasible. Subfertility therapy focuses on lifestyle modifications and learning how to boost your chances of getting pregnant.

    If medical treatment or other choices are required, they are available.

    Increasing the chances of conception

    Here are some lifestyle adjustments and ideas that might help you conceive naturally:

    • Avoid smoking, which can have an impact on both male and female fertility.
    • Stop consuming booze.
    • Maintain a healthy weight because being underweight or overweight might have an impact on fertility.
    • Use ovulation prediction kits to determine the optimal time to have intercourse throughout your period.
    • Keep track of your basal body temperature to see when you're most fertile.
    • Saunas, for example, might have a negative impact on sperm production and motility.
    • Reduce your intake of caffeine, which has been related to women's Subfertility 
    • Consult your doctor about your medicines, since some are known to interfere with fertility.


    Medical treatment

    The medical treatment will be determined by the reason of the infertility or subfertility. Males and females are treated differently.

    • Men's Treatment

    Treatment options for males may include addressing sexual health issues or:

        • Repair of a varicocele or obstruction
        • Drugs to increase testicular function, such as sperm count and quality 
        • Sperm retrieval procedures to collect sperm in guys who have difficulty ejaculating or whose ejaculated fluid lacks sperm


    • Women's Treatment

    There are several treatments available to assist restore female fertility. To conceive, you may require simply one or a mix of several.

    These are some examples:

        • Fertility medicines are used to control or stimulate fertility, while uterus surgery is used to address uterine issues.
        • IUI (intrauterine insemination), which involves inserting healthy sperm into the uterus 


    Assisted reproductive technologies

    Any fertility therapy or process that involves the management of the egg and sperm is referred to as assisted reproductive technology (ART).

    The most prevalent ART method is in vitro fertilization (IVF). It entails extracting eggs from a woman's ovaries and fertilizing them with sperm. After that, the embryos are put into the uterus.

    Other procedures may be performed during IVF to improve the chances of pregnancy.

     These are some examples:

    • Intracytoplasmic sperm injection (ICSI), in which a healthy sperm is injected directly into an egg
    • Assisted hatching, which aids implantation by opening the outer covering of the embryo 
    • Donor sperm or eggs, which may be used if there are severe problems with either the eggs or the sperm
    • Gestational carrier, which is an option for women who do not have a functional uterus or who are considered high-risk for pregnancy



    Adoption is a possibility if you are unable to conceive or are looking for alternatives to medical infertility therapy. Adoption blogs are an excellent source of information on adoption and perspective from people who have gone through the adoption process.



    Subfertility occurs when attempting to conceive takes longer than planned. Although this might be discouraging, some lifestyle adjustments can help you conceive.