Chapter 1 Subfertility – a logical approach Gab Kovacs

The introductory point I would like to make is that the term “infertility” is no longer applicable and we should be referring to “subfertility”. The Oxford Dictionary defines “infertility” as “not capable of producing offspring; barren”. With the advances in treatment over the last three decades, the development of IVF, the use of intracytoplasmic sperm injection (ICSI), application of testicular biopsy, oocyte donation, sperm donation and surrogacy, there is no couple who cannot potentially conceive, so the term “infertility” should no longer be used. Therefore, this book is called the “Subfertility Handbook”. The probability of conception depends on the success rate of the particular treatment, and the number of cycles of treatment that a couple undertake. This has been applied to the “lifetable” analysis of repeated treatment cycles by donor insemination [1], ovulation induction [2], and IVF [3]. The “life-table” concept, which takes into consideration what may happen to couples who have not yet had all their treatment cycles, suggests that if a couple keep trying, they should eventually all conceive. The concept of “if at first you don’t succeed, try, try, try again” was proven by a report of a woman who successfully conceived after 37 cycles of IVF treatment (fresh and frozen) [4]. The investigation and treatment of a couple who have failed to conceive is like putting a jig-saw together. There are the three main fertility parameters (eggs, sperm, and tubes) (Figure 1.1), and if these are found to be relatively normal and the couple still does not conceive, we have what is termed “unexplained or idiopathic subfertility”. If a problem is identified, then that should be corrected. The first factor is “are sufficient number of normal sperm placed in the right place at the right time”? As described in detail in Chapter 3 this requires determining that the timing of intercourse is appropriate and that penetration is adequate. The next step then is to assess sperm quality by semen analysis. If there is a significant male factor, there is only a small chance that an effective treatment to improve semen quality is available (Chapter 7), but fortunately it has been recognized for 25 years now that IVF has an important place in the treatment of male factor subfertility. Using standard IVF can be described as “taking the mountain to Mohammed”, where many men have sufficient sperm to fertilize their partner’s oocyte in vitro whereas they cannot do so naturally [5]. With the development of ICSI [6] men with very few sperm and even men with azoospermia can have a handful of sperm extracted and can now fertilize oocytes. The only men who cannot produce embryos are those with a total lack of sperm. Even this may be overcome in the future with haploidization of human cells [7] or the cloning of sperm cells.