Subfertility treatment in the 21st Century

Blog Post by Gab Kovacs, International Medical Director, Monash IVF, and Professor of Obstetrics and Gynaecology, Monash University, Toorak, Victoria, Australia

The approach to subfertility has certainly changed in the last few decades. Couples’ expectations have changed, and the community now accepts that there is no longer “infertility”. With all the various methods of parenting, every couple can have a family, thus “Subfertility” is a more accurate term.

 The principles of investigating a couple have not changed, it is still considering the “eggs”, “sperm” and “tubes” as the primary fertility parameters. If these are normal we then consider the couple as “idiopathic subfertility” and we contemplate whether there is a problem in gamete/embryo transport,  fertilization or implantation.  Whilst in-vitro fertilization techniques can help with the first two, implantation failure is still an ongoing challenge.  In fact it merges with the problem of recurrent early pregnancy loss, another problem area of reproductive medicine.

The approach  to investigating a couple follows the usual clinical principles of “history”, “examination” and “investigations”. Decisions have to made with respect to which investigations are “cost-effective”, not just in a financial but also at a personal level.

No longer should we be sending  a couple away to “keep trying” until 12 months have passed. Many women are delaying pregnancy and they do not have 12 months to waste. If a couple are concerned enough to seek help, they should be investigated, but an astute clinician should be able to recommend which tests to do and how quickly. Semen analysis is easy, and should be done early, taking a history should  suggests problems in ovulation.

With respect to treatment, if regular ovulation is not occurring, that is usually easily treated. If the sperm quantity/quality is significantly abnormal, there is usually little that can be done without IVF. Assessing and treating tubal abnormality or pelvic endometriosis is more controversial.  Investigating unexplained subfertility, the role of intrauterine insemination and empirical clomiphenes citrate are more complicated.

Nevertheless there is always IVF as a last resort, which solve most problems, especially if we include the use of donor gametes, embryo donation and surrogacy.

Gab Kovacs is editor of The Subfertility Handbook, A Clinician’s Guide ,  published by Cambrdge University Press