FFinalistSouthampton · 2027
Obstetrics & gynaecology
AKT · Obstetrics & gynaecology/Menstrual & benign gynae

Infertility & subfertility

Ovulatory, tubal, uterine, male-factor or unexplained

Overview

Failure to conceive after 12 months of regular unprotected intercourse (roughly every 2–3 days). About 84% of couples conceive within a year. Causes divide roughly into male factor (30%), ovulatory (25%), tubal (20%) and unexplained (25%) — which is why BOTH partners are investigated from the outset.

Recognise

  • Take a history from both partners — it is a couple's diagnosis, not a woman's
  • Ovulatory clues: cycle regularity, PCOS features (oligomenorrhoea, hirsutism, acne), galactorrhoea, thyroid symptoms
  • Tubal clues: previous pelvic inflammatory disease, chlamydia, ectopic pregnancy, endometriosis, pelvic surgery
  • Male factor: previous paternity, undescended testes, mumps orchitis, varicocele, chemotherapy, anabolic steroid use
  • Modifiable factors that genuinely matter: BMI (both high and low), smoking, alcohol, recreational drugs, and heat exposure in men

Red flags

  • Amenorrhoea with hot flushes and a raised FSH in a woman under 40 → premature ovarian insufficiency; refer promptly, and treat the bone and cardiovascular consequences

Differentials & how to tell them apart

Polycystic ovary syndromeOligo/anovulation with clinical or biochemical hyperandrogenism and polycystic ovaries — the commonest ovulatory cause
Tubal factorNormal ovulation and normal semen, with blocked tubes on HSG and often a chlamydia or PID history
EndometriosisCyclical pelvic pain, dysmenorrhoea and deep dyspareunia
Premature ovarian insufficiencyUnder 40 with amenorrhoea, raised FSH on two occasions and low oestradiol
Male factorAbnormal semen analysis on two samples — present in around a third of couples
HyperprolactinaemiaGalactorrhoea with oligomenorrhoea and a raised prolactin; check for drugs and a pituitary adenoma

Investigations

Both partners, early. Female: mid-luteal progesterone (day 21 of a 28-day cycle — i.e. 7 days BEFORE the next expected period, adjusted for cycle length) to confirm ovulation; chlamydia screen; rubella immunity; TFT and prolactin if indicated; tubal assessment by hysterosalpingography or HyCoSy, or laparoscopy with dye if pathology is suspected; ovarian reserve by AMH or antral follicle count. Male: semen analysis, repeated after 3 months if abnormal. Advise 400 micrograms folic acid daily (5 mg if higher risk).

Management

Investigate both partners after 12 months — or after 6 months if the woman is 36 or over, or there is a known cause

  1. 1Advise and optimise: intercourse every 2–3 days, folic acid, smoking cessation, alcohol reduction, BMI toward 19–30. Do not medicalise before 12 months in a young couple with no risk factors.
  2. 2Investigate both partners as above.Gate: Woman aged 36 or over, known tubal/uterine disease, previous chemotherapy, or amenorrhoea → refer EARLY rather than waiting the full 12 months
  3. 3Refer to a specialist fertility service for ovulation induction, intrauterine insemination or IVF according to cause. NICE recommends offering IVF to women under 43 who have not conceived after 2 years of regular unprotected intercourse or 12 cycles of insemination — though local funding criteria vary considerably.
Folic acid 400 micrograms daily — From the outset — 5 mg if diabetic, on antiepileptics, BMI ≥30, or a previous neural tube defect
Letrozole or clomifene — Ovulation induction in anovulatory PCOS — specialist initiation and monitoring
Metformin — Adjunct in PCOS, particularly with insulin resistance

Key points

Two things earn marks. The mid-luteal progesterone is timed 7 days before the NEXT expected period, not rigidly on day 21 — for a 35-day cycle that is day 28. And the investigation is always of the couple: ordering only female tests when a third of causes are male factor is the classic error.

Monitor & prognosis

Track ovulation biochemically rather than by temperature charts, which NICE advises against as unreliable.

Around half of couples who have not conceived in the first year will do so in the second without intervention. Age is the dominant prognostic factor throughout.

Source: NICE CG156 — fertility problems: assessment and treatment