Subfertility
Subfertility is the failure of a couple to conceive after 12 months of regular unprotected intercourse, indicating reduced but not necessarily absent reproductive capacity.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Male factor (abnormal semen analysis) [2] | Partner's semen analysis abnormal; Hx of mumps/cryptorchidism/varicocele | 「你先生有冇做過精液檢查？」 | ~30% |
| Anovulation (most commonly PCOS) [2] | Irregular/absent menses, obesity, hirsutism, acne, LH:FSH > 2.5 | 「月經準唔準？有冇多毛或者暗瘡？」 | ~25% | |
| Tubal factor (post-PID/endometriosis) [2] | Hx of PID, STI, pelvic surgery, ectopic pregnancy | 「以前有冇試過盆腔發炎？」 | ~15% | |
| Serious Not To Miss | Pituitary tumour (prolactinoma) | Galactorrhoea, visual field defect, headache | 「有冇頭痛？視力有冇變？乳頭有冇出奶？」 | ~2% |
| Premature ovarian insufficiency (POI) | Age < 40, amenorrhoea, ↑FSH, menopausal Sx | 「你幾大？有冇潮熱或者出汗？」 | ~2% | |
| Testicular cancer / undescended testis | Testicular mass, Hx cryptorchidism → infertility [3] | 「你先生有冇發現陰囊有硬塊？」 | ~1% | |
| Pitfalls | Coital dysfunction / infrequent intercourse | May not volunteer this; timing completely off | 「你哋幾密行房？有冇困難？」 | ~10% |
| Endometriosis | Cyclical pelvic pain, dyspareunia, tender nodules in POD on exam | 「嚟M之前有冇肚痛？行房深入時痛唔痛？」 | ~10% | |
| Asherman syndrome | Secondary amenorrhoea post-D&C/TOP | 「之前做完手術之後月經有冇變少或者冇咗？」 | ~1% | |
| Masquerades | Diabetes / insulin resistance (PCOS overlap) | Obesity, acanthosis nigricans, FHx DM | 「有冇糖尿病？頸或者腋下皮膚有冇變深色？」 | ~5% |
| Hypothyroidism [4] | Fatigue, weight gain, cold intolerance, constipation; ↑TSH | 「有冇成日覺得好攰、怕凍、便秘？」 | ~3% | |
| Drugs (antipsychotics, opioids, anabolic steroids) | Medication Hx → ↑PRL or ↓gonadotropins | 「有冇食緊精神科藥或者補品？」 | ~3% | |
| Trying to Tell Me Something? | Marital/family pressure, relationship strain | Couple rarely intimate; in-law pressure to conceive | 「屋企人有冇催你哋？你哋關係點？」 | ~25% |
| Depression / anxiety about fertility | Low mood, guilt, self-blame, social withdrawal | 「你心情點？有冇覺得好大壓力？有冇怪自己？」 | ~20% | |
| Fear of being "the cause" / past history (e.g. STI, TOP) | Won't volunteer unless asked sensitively | 「有啲人會擔心係自己問題，你有冇咁諗？以前有冇嘢想講但唔知點開口？」 | ~10% |
Minute-by-Minute 6-Minute Consultation
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, open question | 「你好，我係X醫生，今日想了解下你嘅情況。你今日嚟有咩想同我傾？」("Hi, I'm Dr X, I'd like to understand your situation. What brings you here today?") | Friendly opening, builds rapport, open-ended = interpersonal marks |
| 0:30–1:30 | HPI: duration trying, cycle, coital frequency, prior pregnancies | 「你哋試咗幾耐？月經準唔準？大概幾多日一次？你同先生大概幾密有行房？之前有冇試過懷孕？」 | Core subfertility history; defines primary vs secondary; duration determines urgency |
| 1:30–2:30 | Targeted Hx: female factors (menstrual, PID, surgery, galactorrhoea, thyroid, weight), male factors (occupation, heat, mumps, undescended testis) | 「月經嚟嗰時有冇經痛？有冇試過流嘢或者下面發炎？有冇乳頭出奶？怕唔怕凍或者怕熱？你先生做咩工作？有冇長時間坐？」 | Identifies ovulatory, tubal, endocrine & male-factor causes |
| 2:30–3:30 | Red flags, PMHx, DHx, sexual Hx, FHx | 「你有冇食緊乜嘢藥？有冇做過手術？屋企人有冇生仔方面嘅問題？你哋行房有冇困難或者唔舒服？」 | Drugs (e.g. metformin, hormones), sexual dysfunction, FHx of premature menopause |
| 3:30–4:30 | ICE: Ideas, Concerns, Expectations | 「你自己覺得係咩原因？你最擔心嘅係咩？你今日嚟最希望我點幫到你？」 | Directly scores ICE marks on CRF; uncovers hidden agenda |
| 4:30–5:15 | Psychosocial screen: relationship stress, work, mood, family pressure | 「呢件事有冇影響到你哋感情？你心情點？屋企人有冇畀你壓力？」 | Biopsychosocial marks; hidden agenda often = marital/family pressure |
| 5:15–6:00 | Summarise, signpost plan, check understanding, close | 「咁我總結一下…我建議安排一啲基本檢查，之後再同你詳細傾。你有冇嘢想問？」 | Closing skills; safety-net; shared decision-making |
Uncovering the hidden agenda: The patient may present with "wanting a baby" but the real concern could be: marital pressure, fear of being "the problem," anxiety about age-related decline, guilt about past TOP/STI, or sexual dysfunction. Always ask 「你最擔心嘅係邊方面？」 and 「嚟之前有冇諗過自己有咩問題？」.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Duration | How long have you been trying to conceive? | 「你哋試咗幾耐想生BB？」 | Subfertility defined as failure to conceive after ≥12 months of regular unprotected intercourse [1]. If > 2 yrs or age ≥ 35, earlier referral needed | Refer if ≥ 12 months; if ≥ 35 yo, investigate after 6 months |
| Coital frequency & timing | How often do you have intercourse? Do you time it? | 「你哋大概幾密行房？有冇計排卵期？」 | Infrequent coitus and sexual dysfunction are important causes of infertility [1] | Infrequent coitus, erectile dysfunction, vaginismus |
| Menstrual Hx | Are your periods regular? Cycle length? Duration? | 「月經準唔準？幾多日一次？嚟幾多日？」 | Irregular/absent menses → anovulation (PCOS is the commonest cause of anovulation) [2] | PCOS, hypothalamic amenorrhoea, hyperprolactinaemia, POI |
| Dysmenorrhoea / dyspareunia | Any pain with periods or during intercourse? | 「嚟M有冇好痛？行房有冇痛？」 | Suggests endometriosis or PID sequelae → tubal factor | Endometriosis, pelvic adhesions |
| Past pregnancies | Any previous pregnancies, miscarriages, or terminations? | 「之前有冇懷過孕？小產？或者做過人工流產？」 | Distinguishes primary vs secondary subfertility; past TOP → Asherman's, tubal infection risk | Secondary subfertility, Asherman syndrome, ectopic Hx |
| Galactorrhoea | Any milk discharge from nipples? | 「乳頭有冇出奶？」 | Hyperprolactinaemia → anovulation | Prolactinoma, drug-induced |
| Thyroid symptoms | Weight change, heat/cold intolerance, fatigue? | 「體重有冇變？怕唔怕凍或者怕熱？」 | Both hypo- and hyperthyroidism impair fertility | Hypothyroidism, hyperthyroidism |
| Weight / exercise / stress | Any significant weight change, excessive exercise, stress? | 「體重有冇大上大落？做好多運動？壓力大唔大？」 | BMI extremes → hypothalamic amenorrhoea or anovulation (obesity and low BMI both affect fertility) [2] | Hypothalamic amenorrhoea, PCOS with obesity |
| Hirsutism / acne | Excess hair growth? Acne? | 「面或者身有冇多咗毛？有冇暗瘡？」 | Hyperandrogenism → PCOS | PCOS, congenital adrenal hyperplasia |
| PID / STI history | Any past pelvic infections or STIs? | 「以前有冇試過下面發炎或者性病？」 | Tubal damage → tubal factor infertility | Tubal blockage, hydrosalpinx |
| Pelvic surgery | Any abdominal or pelvic surgery? | 「有冇做過肚或者婦科手術？」 | Adhesions → tubal/peritoneal factor | Post-surgical adhesions |
| Male factor: partner's Hx | Partner's age? Occupation? Hx of mumps, undescended testis, surgery? | 「你先生幾大？做咩工？細個有冇生過痄腮（mumps）？有冇隱睪？」 | Male factor accounts for ~30–40% of subfertility [2]; occupational heat exposure, cryptorchidism → impaired spermatogenesis | Male factor: varicocele, obstructive azoospermia |
| Drug history | Any medications? Herbal remedies? Supplements? | 「有冇食緊乜嘢藥？補品？」 | NSAIDs, metformin, antipsychotics (↑PRL), testosterone, anabolic steroids suppress spermatogenesis | Drug-induced anovulation, drug-induced azoospermia |
| Smoking / alcohol | Smoking? Alcohol? | 「有冇食煙？飲酒？」 | Both reduce fertility in M & F | Lifestyle modification needed |
| Family Hx | Family Hx of premature menopause, genetic conditions? | 「屋企人有冇好早收經？有冇遺傳病？」 | POI, genetic causes (e.g. Turner mosaicism, CF in males) | Premature ovarian insufficiency |
| Sexual dysfunction | Any difficulty with erection or penetration? Pain? | 「行房順唔順利？有冇困難？」 | 32.5% of subfertile women had sexual dysfunction [1] | Erectile dysfunction, vaginismus, dyspareunia |
| Psychosocial | How is this affecting your relationship and mood? | 「呢件事對你哋關係有冇影響？心情點？」 | Depression/anxiety common; family pressure in HK culture | Adjustment disorder, marital discord, performance anxiety |
Case Report Form Answer Builder
- Chief complaint: Subfertility — inability to conceive after ___ months/years of regular unprotected intercourse
- HPI high-yield points to capture:
- Duration of trying; primary vs secondary (any prior pregnancies)
- Menstrual history: regularity, cycle length, dysmenorrhoea, intermenstrual bleeding
- Coital frequency and timing
- Partner details: age, any known male-factor issues
- Associated symptoms: galactorrhoea, hirsutism, weight change, thyroid symptoms, dyspareunia
- Past gynaecological/surgical Hx: PID, STI, ectopic, D&C, pelvic surgery
- Drug Hx, smoking, alcohol
- Relevant investigations done
Examples: "Wants investigation for inability to conceive after 2 years" / "Referred by MCHC for subfertility workup" / "Family pressure to conceive; worried about declining fertility with age"
- How to phrase: State the patient's main agenda in one sentence. It may NOT be "subfertility" alone — it could be "worried about age-related fertility decline" or "in-law pressure to have a baby."
| Likely Content | Exact Wording for CRF | |
|---|---|---|
| Idea | "I think something is wrong with my womb/eggs" or "Maybe my husband has a problem" | Patient thinks she may have a problem with ovulation / blocked tubes / her husband may have low sperm count |
| Concern | "Am I too old?" / "Will I never be able to have children?" / "Is it my fault because of the previous termination?" | Patient is worried that her age is making it harder / fears permanent infertility / worries that past TOP caused damage |
| Expectation | "I want tests" / "I want a referral to a fertility specialist" / "I want to know if IVF is needed" | Patient expects investigation and possible referral for fertility treatment |
Anovulatory infertility (PCOS) — if stem shows irregular menses, obesity, hirsutism
OR choose based on stem cues:
- Irregular menses → Anovulation (PCOS most likely)
- Normal menses + Hx PID → Tubal factor
- Normal female Hx → Male factor (always consider)
- Minimum supporting evidence: Irregular menses ≥ 35-day cycles + clinical hyperandrogenism (acne/hirsutism) + duration > 12 months → Anovulatory subfertility (PCOS)
| DDx | Key Discriminator |
|---|---|
| Male factor infertility | Abnormal semen analysis; Hx of cryptorchidism, varicocele, mumps orchitis [3] |
| Tubal factor infertility | Hx of PID/STI, pelvic surgery, ectopic pregnancy; confirmed by HSG/laparoscopy |
| Endometriosis | Cyclical pelvic pain, dysmenorrhoea, dyspareunia; tender nodules on PV exam |
| Domain | Problem |
|---|---|
| Biological | Anovulation / irregular menstrual cycles reducing fertility potential |
| Psychological | Anxiety and low mood related to inability to conceive; self-blame; performance anxiety during intercourse |
| Social | Family/in-law pressure to produce offspring; marital strain; potential work impact from frequent clinic visits |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Anovulation (PCOS) | Hirsutism (modified Ferriman-Gallwey score) | Inspect face (upper lip, chin), chest, lower abdomen, thighs for terminal hair | Clinical hyperandrogenism — a diagnostic criterion for PCOS |
| PCOS (additional) | Acanthosis nigricans | Inspect neck, axillae for velvety darkened skin | Insulin resistance associated with PCOS |
| PCOS (additional) | Central obesity, raised BMI | Measure waist circumference, calculate BMI | Obesity worsens anovulation in PCOS |
| Male factor | Small / soft testes; varicocele ("bag of worms") [5] | Palpate testes for size/consistency; examine standing for varicocele with Valsalva | Small testes → impaired spermatogenesis; varicocele → ↑scrotal temperature |
| Tubal factor | No reliable physical sign in brief FM station | Adnexal tenderness/mass on bimanual exam may suggest hydrosalpinx; best confirmed by HSG | Exam usually normal; rely on Hx of PID/STI |
| Endometriosis | Tender nodularity in posterior fornix on PV exam | Bimanual and speculum exam (unlikely in FM OSCE); fixed retroverted uterus | Pathognomonic of deep infiltrating endometriosis |
| Hypothyroidism | Delayed relaxation of ankle reflexes; dry skin; bradycardia | Test ankle jerk; inspect skin; check pulse | Hypothyroidism is a treatable cause of subfertility |
| Hyperprolactinaemia | Galactorrhoea | Gentle expression of nipple (with consent) | Elevated prolactin suppresses GnRH → anovulation |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting male factor — male causes account for 30–40% of subfertility. ALWAYS ask about the partner's history and semen analysis.
- Not asking coital frequency/timing — infrequent intercourse is a common and easily missed cause.
- Not asking about sexual dysfunction — vaginismus, erectile dysfunction, and dyspareunia are frequently overlooked [1].
- Ignoring psychosocial impact — students lose biopsychosocial marks by not exploring relationship strain, mood, and family pressure.
- Writing "infertility" instead of "subfertility" — in FM, use "subfertility" (implies possibility); "infertility" implies absolute inability.
- Forgetting ICE — the patient's fear (e.g. "Is it because of my age?") is often the real reason for consultation.
- Not screening for red flags — galactorrhoea (prolactinoma), visual field defects, premature menopausal symptoms (POI).
- Amenorrhoea + hot flushes in woman < 40 → POI — urgent O&G referral
- Galactorrhoea + headache + visual field defect → pituitary macroadenoma — urgent endocrine/neurosurgical referral
- Testicular mass → testicular cancer — urgent urology referral [3]
- Recurrent miscarriages (≥3) → antiphospholipid syndrome workup [6]
「我哋今日傾完，我會幫你安排一啲基本檢查，包括驗血同埋你先生嘅精液分析。如果有需要，我會轉介你去專科跟進。你有冇其他問題想問？」
(I'll arrange some basic tests including blood tests and your husband's semen analysis. If needed, I'll refer you to a specialist. Any other questions?)
Key investigations to mention (for closing/safety-net):
- Female: Day 2–3 FSH/LH/E2, prolactin, TFT, mid-luteal progesterone (Day 21), pelvic USS
- Male: Semen analysis (×2, at least 3 months apart)
- If indicated: HSG (tubal patency), karyotype, anti-Müllerian hormone (AMH) for ovarian reserve
High Yield Summary
What to ASK: Duration trying, menstrual regularity, coital frequency/timing, sexual dysfunction, partner Hx (male factor), galactorrhoea, thyroid Sx, PID/STI Hx, past pregnancies/TOP, drug Hx, psychosocial impact (mood, relationship, family pressure), ICE.
What to WRITE on CRF: Primary/secondary subfertility × duration; menstrual pattern; coital details; partner factors; ICE clearly stated; most likely Dx supported by Hx findings; always include male factor as a DDx; biopsychosocial problems including psychological distress and family/social pressure.
What NOT to MISS: Male factor (30–40%), sexual dysfunction/infrequent coitus, hypothyroidism, hyperprolactinaemia, POI in young woman, endometriosis masquerading as "just period pain," psychosocial hidden agenda (family pressure, past guilt).
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: MBBS_SRH_2025.8.10.pdf (slides 35, 37, 43) — sexual dysfunction prevalence in subfertile women; fecundability and age; preconception care objectives [2] Lecture slides: GC 117. I want to have a baby male and female infertility.pdf / Block C - I want to have a baby_ male and female infertility.pdf — PCOS as commonest anovulatory cause; male factor proportion; tubal factor; obesity and BMI effects [3] Senior notes: Maksim Surgery Notes.pdf (p.326) — testicular tumour risk factors including cryptorchidism and infertility; MBBS Final MB (Surgery) (Felix PY Lai).pdf (p.1095) — undescended testis consequences including infertility [4] Senior notes: Block A - I am losing weight and sweating all the time_ causes of severe, weight loss; thyrotoxicosis; hypothyroidism.pdf (p.43) — TSH targets in pregnancy; hypothyroidism and fertility [5] Senior notes: Ryan Ho Urogenital.pdf (p.234) — varicocele clinical features, association with decreased fertility; Ryan Ho Fundamentals.pdf (p.157) — small firm testes in hypogonadism [6] Senior notes: Block A - Leg swelling and chest pain_ deep vein thrombosis; pulmonary embolism; Thrombophilia.pdf (p.14) — antiphospholipid syndrome and recurrent fetal loss
Skin Ulcers
Skin ulcers are open lesions resulting from the loss of the epidermis and part or all of the dermis, often caused by vascular insufficiency, prolonged pressure, neuropathy, or infection, and characterized by impaired or delayed healing.
Suprapubic / Pelvic Pain
Suprapubic or pelvic pain is discomfort localized to the lower abdomen below the umbilicus, commonly arising from urinary, gynecological, gastrointestinal, or musculoskeletal pathology affecting the pelvic organs or structures.