Elsevier

The Lancet

Volume 360, Issue 9327, 13 July 2002, Pages 151-159
The Lancet

Seminar
Female subfertility

https://doi.org/10.1016/S0140-6736(02)09417-5Get rights and content

Summary

With an average monthly fecundity rate of only 20%, human beings are not fertile mammals. 10–15% of couples have difficulties conceiving, or conceiving the number of children they want, and seek specialist fertility care at least once during their reproductive lifetime. Dependent on the two main factors that determine subfertility, duration of childlessness and age of the woman, three questions need to be addressed before treatment is offered. Is it time to start the routine fertility investigation?—ie, has sufficient exposure to the chance of conception taken place? Are cost-effective, safe, and reliable treatments available for the disorder diagnosed? And, should the couple be referred straightaway for assisted reproduction?

Section snippets

Epidemiology

High-quality epidemiological data to corroborate the figure of 10–15% did not become available until 1985, when Hull and co-workers published the results of a study4 in which they assessed subfertility procedures in 708 couples in a health district in England. The group concluded that at least one in six couples need specialist help at some point in their lives because of inability to conceive (primary subfertility), or to conceive the number of children they wanted (secondary subfertility).

Monthly fecundity rates (MFR)

Subfertility is a difficult problem to study. Whereas most complaints that make patients go to doctors consist of obvious signs or symptoms, it is the absence of a child that encourages couples to visit a fertility specialist. The problem of infertility is compounded by the fact that most couples who seek treatment are not sterile, but have decreased fertility; they are subfertile, and many of them will eventually conceive spontaneously. For the sake of this seminar, infertility (or sterility)

Prognostic factors and diagnostic tests

Treatment-independent and treatment-dependent pregnancy outcome depends greatly on duration of childlessness4, 6, 16, 17, 18, 19 and on the age of the woman.4, 6, 16, 20 However, other factors can also affect fertility. It is noteworthy that, in each subset of patients, the individuals with the most severe conditions contribute the most information with respect to the outlook for that subset.

Outlook-oriented subsets of subfertility

Five distinct subsets of subfertility disorders exist: male subfertility, ovulation disturbances, defects in spermatozoa-cervical mucus interaction, tuboperitoneal disorders, and unexplained subfertility (table 3).4, 6, 16 The rationale for discerning these five diagnostic subsets lies in the fact that each has an individual treatment-independent pregnancy outlook, and each also has its own specific treatment-dependent outlook with respect to non-ART treatment.

Assisted reproduction, the 2002 panacea

The introduction of IVF in 197884 has had a great effect on diagnosis and treatment of fertility disorders. The potential need for IVF and related services is high because assisted reproduction is thought the only effective option for many couples. Although the rapid and widespread introduction of IVF, ICSI, and related technologies into the clinic has been technology-driven rather than evidence-based, ART has become the gold standard with which other treatments are compared. However, such

Conclusion

Treatment for subfertility has evolved from a plethora of largely unsubstantiated diagnostic tests and empirical treatments into an advanced set of clinical diagnostic tests, allowing identification of outlook-oriented subsets of subfertility and their treatment. Appropriate effective therapies are available, but many treatments deserve further scientific scrutiny. Prospective studies are urgently needed to establish the factual discriminatory power of diagnostic fertility tests. The clinical

Search strategy

I did a search of published work (Medline 1966–2001; Cochrane controlled trials register, and database of systematic reviews 2001) for each prognosis-oriented subset: male subfertility, ovulation disturbances, spermatozoa-cervical mucus interaction defects, tuboperitoneal disorders, and unexplained subfertility. Because of the broad nature of the topics covered, I have focused on evidence from randomised controlled trials where possible, and on structured systematic reviews, as retrieved by the

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