Clinical Review

Management of infertility

BMJ 2002; 325 doi: (Published 06 July 2002) Cite this as: BMJ 2002;325:28
  1. D J Cahill, consultant senior lecturer in reproductive medicinea,
  2. P G Wardle, consultant obstetrician and gynaecologist (
  1. aUniversity of Bristol Division of Obstetrics and Gynaecology, St Michael's Hospital, Bristol BS2 8EG
  2. bDepartment of Women's Health, Cotswold Centre, Southmead Hospital, Bristol BS10 5NB
  1. Correspondence to: P G Wardle

    Delay in childbearing and the adverse effect of increasing age on women's fertility have increased referrals for fertility investigations and treatment. In the past 25 years the percentage of births to women age 30 and over in England and Wales has doubled (see fig A on 1 2 One in six couples require referral for investigation or treatment for subfertility.3 Couples are more aware of what can be done from media attention. Unfortunately, this often leads to falsely high expectations of fertility treatments. Natural human fertility is low compared with most other species. Peak human fertility (the chance of pregnancy per menstrual cycle in the most fertile couples) is no higher than 33%, and it is unrealistic to expect a higher chance of pregnancy than this from any fertility treatment. This review of the management of infertility, or more correctly subfertility, focuses on investigations (including over the counter fertility tests) and appropriate actions and treatments in response to test results.

    Summary points

    Natural human fertility is low, and most couples have falsely high hopes of fertility treatments

    The major causes of subfertility are sperm dysfunction, ovulation disorder, and fallopian tube damage

    Most investigations to establish a cause of subfertility are simple to undertake

    For most couples, history and examination will not indicate a cause, and full subfertility investigations will be needed

    Couples with sperm dysfunction or likely tubal damage should be referred early for specialist opinion

    Ovulation disorders often respond to simple treatments that can be safely initiated in primary care


    This article is based on 20 years' combined experience of running tertiary infertility clinics, together with the resources and regularly updated literature searches we have used over the past 14 years in preparation for annual postgraduate study days for primary care doctors.

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